reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 314.00 - Rates for Dental Services › Section 314.08 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 314.00 are severable. If any
				provision of 101 CMR 314.00 or application of any provision to an applicable
				individual, entity, or circumstance is held invalid or unconstitutional, that
				holding will not be construed to affect the validity or constitutionality of
				any remaining provisions of 101 CMR 314.00 or application of those provisions
				to applicable individuals, entities, or circumstances.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 315.00 - Rates for Vision Care Services and Ophthalmic Materials › Section 315.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope
.
			 101 CMR
			 315.00 governs the rates of payment used by
			 governmental units and purchasers under M.G.L. c. 152, § 1
et
			 seq.
(the Workers' Compensation Act) for vision-care services and
			 ophthalmic materials provided to publicly aided and industrial accident
			 patients.
(2)
Applicable Dates of Service
. Rates contained in
			 101 CMR
			 315.00 are effective for dates of service on or after
			 February 1, 2023.
(3)
Disclaimer of Authorization of Services
.
			 101 CMR
			 315.00 is not authorization for or approval of the
			 procedures for which rates are determined pursuant to
			 101 CMR
			 315.00. Governmental units that purchase care are
			 responsible for the definition, authorization, and approval of care and
			 services provided to publicly aided clients.
(4)
Administrative
			 Bulletins
. EOHHS may issue administrative bulletins to clarify
			 provisions of
			 101 CMR
			 315.00, or to issue coding updates and corrections
			 under
			 101
			 CMR 315.01(5).
(5)
Coding Updates and
			 Corrections
. EOHHS may publish service code updates and
			 corrections in the form of administrative bulletin. Updates may reference
			 coding systems including, but not limited to, the American Medical
			 Association's Current Procedural Terminology (CPT) and the Healthcare Common
			 Procedure Coding System (HCPCS). The publication of such updates and
			 corrections will list:
(a) codes for which
			 the code numbers change, with the corresponding cross references between the
			 new codes and the codes being replaced. Rates for such updated codes are set at
			 the rate of the code that is being replaced;
(b) codes for which the code numbers remain
			 the same but the description has changed;
(c) deleted codes for which there are no
			 corresponding new codes; and
(d)
			 codes for entirely new services that require pricing. EOHHS will list these
			 codes and apply individual consideration (I.C.) payment for these codes until
			 appropriate rates can be developed.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 315.00 - Rates for Vision Care Services and Ophthalmic Materials › Section 315.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1)
Rate Determination
. The rates for authorized
			 vision-care services and ophthalmic materials under
			 101 CMR
			 315.00 are the lower of
(a) the provider's usual fee to patients
			 other than publicly aided or industrial accident patients; or
(b) the schedule of allowable fees set forth
			 in 101 CMR 315.04.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 315.00 - Rates for Vision Care Services and Ophthalmic Materials › Section 315.04 - Allowable Fees for Vision-care Services

Current through Register 1525, July 5, 2024
(1)
Modifiers
. The following modifiers are used to adjust
			 payments under the circumstances noted in
			 101
			 CMR 315.04(1)(a) and (b).
(a)
-52 Reduced
			 Services
. Modifier -52 is used to describe circumstances in which
			 services provided were reduced in comparison to the full description of the
			 service. When a provider does not complete a procedure in its entirety, such as
			 a provider electing to partially reduce or eliminate a service, the procedure
			 must be billed by appending modifier -52 to the service code. The rate for
			 services billed with modifier -52 is 86% of the rate listed in
			 101
			 CMR 315.04(2). For example,
			 modifier -52 would be used for a procedure that includes administration of
			 eyedrops when an optometrist who is not certified to distribute eyedrops,
			 performs the procedure.
(b)
Provider Preventable Conditions
. The following
			 modifiers are used to report provider preventable conditions in accordance with
			 42 CFR. 447.26 and result in nonpayment for services.
Modifier
Description
PA
Surgical or other invasive procedure performed on the
							 wrong body part
PB
Surgical or other invasive procedure performed on the
							 wrong patient
PC
Wrong surgical or other invasive procedure performed
							 on a patient
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 315.00 - Rates for Vision Care Services and Ophthalmic Materials › Section 315.05 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101 CMR
				315.00 are severable, and if any provision of
				101 CMR
				315.00 or application of such provision to any
				eligible provider of vision-care services and ophthalmic materials or any
				circumstances shall be held to be invalid or unconstitutional, such invalidity
				shall not be construed to affect the validity or constitutionality of any
				remaining provisions of
				101 CMR
				315.00 or application of such provisions to eligible
				providers of vision-care services and ophthalmic materials or circumstances
				other than those held invalid.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 316.00 - Rates for surgery and anesthesia services › Section 316.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
.
(a) 101 CMR 316.00 governs the payment rates
			 used by all governmental units for surgery and anesthesia services provided to
			 publicly aided patients. Rates for services provided to individuals covered by
			 the Workers' Compensation Act, M.G.L. c. 152, are not set forth in 101 CMR
			 316.00, but are at 114.3 CMR 40.00:
Rates for Services under M.G.L. c.
			 152, Worker's Compensation Act
.
(b) The following laboratory services have a
			 professional and technical component: 83020, 84165, 84166, 84181, 84182, 85390,
			 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, 87207, 88371,
			 88372 and 89060. Payment rates for the professional component are contained
			 herein. Payment rates for the technical component for these codes are contained
			 in 101 CMR 320.00:
Rates for Clinical Laboratory
			 Services
.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 316.00 - Rates for surgery and anesthesia services › Section 316.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1)
Rate Determination
. Rates of payment for services for
			 which 101 CMR 316.00 applies are the lowest of
(a) the eligible provider's usual fee to
			 patients other than publicly aided patients;
(b) the eligible provider's actual charge
			 submitted; or
(c) the allowable
			 fees in accordance with
			 101
			 CMR 316.04 (for anesthesia services), or the
			 schedule of allowable fees set forth in
			 101
			 CMR 316.05 (for surgical services), as
			 applicable, and taking into account appropriate modifiers and any other
			 applicable rate provision(s) in accordance with
			 101
			 CMR 316.03.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 316.00 - Rates for surgery and anesthesia services › Section 316.06 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 316.00 are hereby declared to be
				severable, and if any such provisions or the application of such provisions to
				any person or circumstances shall be held to be invalid or unconstitutional,
				such invalidity shall not be construed to affect the validity or
				constitutionality of any remaining provisions to eligible providers or
				circumstances other than those held invalid.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 317.00 - Rates for Medicine Services › Section 317.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 101 CMR 317.00 governs the payment
			 rates used by all governmental units for medical services provided to publicly
			 aided patients. Rates for services provided to individuals covered by the
			 Workers' Compensation Act, M.G.L. c. 152, are not set forth in 101 CMR 317.00,
			 but are at 114.3 CMR 40.00:
Rates for Services under M.G.L. c. 152,
			 Worker's Compensation Act
.
(2)
Applicable Dates of
			 Service
. Rates contained in 101 CMR 317.00 apply for dates of
			 service on or after May 1, 2024, except as otherwise noted.
(3)
Coverage
.
(a) Payment rates in 101 CMR 317.00 are used
			 to pay for medical services rendered to patients in a private medical office,
			 licensed clinic, hospital, or other inpatient or outpatient facility or
			 department, independent diagnostic testing facility, patient's residence, or
			 other appropriate setting by an individual eligible provider, when an eligible
			 provider bills for the medical services rendered and no other payment method
			 applies.
(b) The rates of payment
			 under 101 CMR 317.00 are full compensation for patient care rendered to
			 publicly aided patients as well as for any related administrative or
			 supervisory duties in connection with patient care. The rates of payment also
			 reimburse all overhead expenses associated with the service provided, without
			 regard to where the care is rendered.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 317.00 - Rates for Medicine Services › Section 317.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1)
Rate
			 Determination
. Rates of payment for services for which 101 CMR
			 317.00 applies are the lowest of
(a) the
			 eligible provider's usual fee to patients other than publicly aided
			 individuals;
(b) the eligible
			 provider's actual charge submitted; or
(c)
1. the
			 schedule of allowable fees set forth in
			 101
			 CMR 317.04(4), taking into
			 account appropriate modifiers and any other applicable rate provision(s) in
			 accordance with
			 101
			 CMR 317.03 or
			 317.04(1);
			 or
2. for drugs, vaccines, and
			 immune globulins administered in a physician's office, the fee specified in
			 101
			 CMR 317.04(1)(a), taking
			 into account any other applicable rate provision(s) in accordance with
			 101
			 CMR 317.04(1).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 317.00 - Rates for Medicine Services › Section 317.04 - Maximum Allowable Fees - Medical Services

Current through Register 1525, July 5, 2024
(1)
Drugs, Medications, Supplies,
			 and Laboratory Specimen Collections
.
(a) Payment rates for drugs, vaccines, and
			 immune globulins administered in a physician's office are equal to the fee
			 listed in the Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing
			 File. For drugs, vaccines, and immune globulins administered in a physician's
			 office that are not listed in the Quarterly ASP Medicare Part B Drug Pricing
			 File, codes are listed in
			 101
			 CMR 317.04(4)  with payment
			 set by I.C., which will apply until such time as the code is listed in the
			 Quarterly ASP Medicare Part B Drug Pricing File.
(b) Supplies and materials used in
			 preparation for or as part of a procedure (
e.g.
, bandages,
			 laboratory kits, syringes, or disposable gloves) are not reimbursed separately,
			 but are included in the office visit rate. In addition, no supplemental charge
			 can be submitted nor payment allowed for routine specimen collection in a
			 physician's office and preparation for clinical laboratory analysis (and
			 activities related thereto),
e.g.
, venipuncture, urine, fecal
			 and sputum samples, culturing, swabbing, and scraping for removal of
			 tissues.
(c) Where applicable,
			 payments for drugs, medicines, supplies, and related materials dispensed to
			 patients are in accordance with rates that are the subject matter of other
			 regulations that may be in effect and germane to the item in question
			 (
e.g.
, laboratory, pharmacy, medical supplies,
etc.
). In other instances where the use of another regulation
			 is not appropriate, certain supplies and materials (except eyeglasses) provided
			 by the physician over and above those usually included with the office visit or
			 other services rendered should be billed under code 99070.
(d) Payment for drugs and/or biologicals may
			 be claimed in addition to an office visit. Drugs that are considered routine
			 and integral to the delivery of a physician's professional services in the
			 course of diagnosis or treatment are not reimbursable. Such drugs are commonly
			 provided without charge or are included in the physician's fee for the service.
Drugs and/or biologicals available free of charge from the
				Massachusetts Department of Public Health are not payable items. When an
				immunization or injection is the primary purpose of an office or other
				outpatient visit, the provider may bill only for the injectable material and
				its administration. Payment for both vaccine administration and an office visit
				is allowable only when the vaccine administration is a medically necessary,
				separately identifiable service.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 317.00 - Rates for Medicine Services › Section 317.05 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 317.00 are severable, and if any such
				provision or the application of such provisions to any person or circumstances
				shall be held to be invalid or unconstitutional, such invalidity shall not be
				construed to affect the validity or constitutionality of any remaining
				provisions to eligible providers or circumstances other than those held
				invalid.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 318.00 - Rates for Radiology Services › Section 318.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 101 CMR 318.00 governs the payment
			 rates used by all governmental units for radiology care and services provided
			 to publicly aided patients. Rates for services provided to individuals covered
			 by M.G.L. c. 152 (the Workers' Compensation Act) are not set forth in 101 CMR
			 318.00, but are at 114.3 CMR 40.00:
Rates for Services under M.G.L. c.
			 152, Worker's Compensation Act
.
(2)
Applicable Dates of
			 Service
. Rates contained in 101 CMR 318.00 apply for dates of
			 service on or after May 1, 2024, except as otherwise noted.
(3)
Coverage
.
(a) Payment rates in 101 CMR 318.00 are used
			 to pay for radiology services rendered to patients in a private medical office,
			 licensed clinic, hospital or other inpatient or outpatient facility or
			 department, independent diagnostic testing facility, patient's residence, or
			 other appropriate setting by an individual eligible provider, when an eligible
			 provider bills for the medical services rendered and no other payment method
			 applies.
(b) The rates of payment
			 under 101 CMR 318.00 are full compensation for patient care rendered to
			 publicly aided patients as well as for any related administrative or
			 supervisory duties in connection with patient care. The rates of payment also
			 reimburse all overhead expenses associated with the service provided, without
			 regard to where the care is rendered.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 318.00 - Rates for Radiology Services › Section 318.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1)
Rate
			 Determination
. Rates of payment for services for which 101 CMR
			 318.00 applies are the lowest of
(a) the
			 eligible provider's usual fee to patients other than publicly aided
			 individuals;
(b) the eligible
			 provider's actual charge submitted; or
(c) the schedule of allowable fees set forth
			 in 101 CMR
			 318.04(3), taking into
			 account appropriate modifiers and any other applicable rate provision(s) in
			 accordance with
			 101
			 CMR 318.03.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 318.00 - Rates for Radiology Services › Section 318.05 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 318.00 are hereby declared to be
				severable, and if any such provisions or the application of such provisions to
				any person or circumstances shall be held to be invalid or unconstitutional,
				such invalidity shall not be construed to affect the validity or
				constitutionality of any remaining provisions to eligible providers or
				circumstances other than those held invalid.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 319.00 - Rates for Doula Services › Section 319.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
.
			 101 CMR
			 319.00 governs the rates of payments used by all
			 governmental units in making payments to eligible doula providers for doula
			 services rendered to publicly aided individuals.
(2)
Applicable Dates of
			 Service
. Rates contained in
			 101 CMR
			 319.00 are effective for dates of service provided on
			 and after December 8, 2023, unless otherwise indicated.
(3)
Coverage
. The
			 rates of payment contained in
			 101 CMR
			 319.00, or determined in accordance with the
			 provisions of
			 101 CMR
			 319.00, are full compensation for doula services
			 rendered to publicly aided individuals as well as for any related
			 administrative or supervisory duties in connection with the provision of
			 services, without regard to where these services are rendered.
(4)
Disclaimer of Authorization
			 of Services
.
			 101 CMR
			 319.00 is not authorization for or approval of the
			 procedures for which rates are determined pursuant to
			 101 CMR
			 319.00. Governmental units that purchase care are
			 responsible for the definition, authorization, coverage policies, and approval
			 of care and services provided to publicly aided individuals.
(5)
Coding Updates and
			 Corrections
. EOHHS may publish service code updates and
			 corrections in the form of an administrative bulletin. Updates may reference
			 coding systems including, but not limited to, the American Medical
			 Association's Current Procedural Terminology (CPT). The publication of such
			 updates and corrections will list
(a) codes
			 for which the code numbers change, with the corresponding cross-references
			 between new codes and the codes being replaced. Rates for such new codes are
			 set at the rate of the code that is being replaced;
(b) codes for which the code number remains
			 the same, but the description has changed;
(c) deleted codes for which there are no
			 corresponding new codes; and
(d)
			 codes for entirely new services that require pricing. EOHHS will list these
			 codes and apply individual consideration (I.C.) payment for these codes until
			 appropriate rates can be developed.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 319.00 - Rates for Doula Services › Section 319.03 - General Rate Provisions and Payment

Current through Register 1525, July 5, 2024
(1)
Individual Consideration and Nonlisted Procedures
.
			 Rates of payment for doula services that are authorized but not listed in
			 101 CMR
			 319.00, services performed in unusual circumstances,
			 and services whose fees are designated by the letters "I.C." are determined on
			 an individual consideration basis.
(2)
Fee Schedule
.
			 Certain doula services are not associated with CPT codes that have a
			 service-specific description, and therefore must be billed for by using a CPT
			 code that represents unlisted services (Unlisted Service Code) in accordance
			 with the fee schedule below. For such doula services, the doula service
			 associated with each Unlisted Service Code is identified in the parenthetical
			 description of the code description section of the fee schedule below.
Code
Rate
Code
						  Description
99600
$100
Unlisted home visit service or procedure. (Perinatal
						  visit up to 60 minutes.)
99600 TF
$150
Unlisted home visit service or procedure. (Perinatal
						  visit from 61 minutes up to 90 minutes. This service must be identified by
						  adding the modifier TF to the parent service code.)
99199
$900
Unlisted special service, procedure or report. (Labor
						  and delivery support.)
(3)
Perinatal Visit Payments
. For MassHealth providers of
			 doula services, the payment for perinatal visits will not exceed $800 per
			 perinatal period per member, with the exception of payment for additional
			 perinatal visits for which a provider receives prior authorization in
			 accordance with 130 CMR 463.000:
Doula
			 Services
.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 319.00 - Rates for Doula Services › Section 319.04 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Required Reports
. Reporting requirements are governed
			 by 957 CMR 6.00:
Cost Reporting Requirements
.
(2)
Penalty for
			 Noncompliance
. The purchasing governmental unit may impose a
			 penalty in the amount of up to 15% of its payments to any provider that fails
			 to submit required information. The purchasing governmental unit will notify
			 the provider in advance of its intention to impose a penalty under 101 CMR
			 319.04(2).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 319.00 - Rates for Doula Services › Section 319.05 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 319.00 are severable. If any
				provision of 101 CMR 319.00 or application of any provision to an applicable
				individual, entity, or circumstance is held invalid or unconstitutional, that
				holding will not be construed to affect the validity or constitutionality of
				any remaining provisions of 101 CMR 319.00 or application of those provisions
				to applicable individuals, entities, or circumstances.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 320.00 - Rates for Clinical Laboratory Services › Section 320.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
.
			 101
			 CMR 320.00 governs the payment rates for clinical
			 laboratory services rendered to publicly aided individuals. The rates set forth
			 in
			 101
			 CMR 320.00 do not apply to individuals covered by
			 M.G.L. c. 152 (the Workers' Compensation Act). Rates for services rendered to
			 such individuals are set forth in 114.3 CMR 40.00:
Rates for Services
			 under M.G.L. c. 152, Workers' Compensation Act
.
(2)
Applicable Dates of
			 Service
. Rates contained in
			 101
			 CMR 320.00 apply for dates of service provided on or
			 after August 1, 2022.
(3)
Coverage
. The payment rates in
			 101
			 CMR 320.00 are full compensation for clinical
			 laboratory services rendered to publicly aided individuals.
(4)
Coding Updates and
			 Corrections
. EOHHS may publish procedure code updates and
			 corrections in the form of an administrative bulletin. Updates may reference
			 coding systems including, but not limited to, the American Medical
			 Association's Current Procedural Terminology (CPT). The publication of such
			 updates and corrections lists
(a) codes for
			 which only the code numbers changed, with the corresponding cross-references
			 between existing and new codes;
(b)
			 deleted codes for which there are no corresponding new codes; and
(c) codes for entirely new services that
			 require pricing. EOHHS may list and price these codes according to the rate
			 methodology used in setting clinical laboratory rates when Medicare fees are
			 available (including, for codes relating to Coronavirus Disease 2019
			 (COVID-19), at 100% of Medicare fees). When Medicare fees are not available,
			 EOHHS may apply individual consideration (I.C.) in reimbursing for these codes
			 until appropriate rates can be developed.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 320.00 - Rates for Clinical Laboratory Services › Section 320.03 - Covered and Excluded Billing Situations

Current through Register 1525, July 5, 2024
(1)
Covered Billing Situations
. Except as provided in 101
			 CMR 320.03(2), the method of determining rates of payment contained in
			 101
			 CMR 320.00 apply to clinical laboratory services
			 provided to publicly aided individuals, with the following conditions.
(a) If clinical laboratory services are
			 performed by an independent clinical laboratory, then the independent clinical
			 laboratory must bill the governmental unit directly. The independent clinical
			 laboratory may not bill indirectly by having a physician or dentist bill either
			 the payer or the patient for services performed by the independent clinical
			 laboratory.
(b) If clinical
			 laboratory services are performed by a registered physician or dentist, or by
			 an agent under his or her direct supervision, in his or her private medical
			 office or clinic, then the registered physician or dentist must bill the
			 governmental unit directly.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 320.00 - Rates for Clinical Laboratory Services › Section 320.04 - General Rate Provisions and Maximum Fees

Current through Register 1525, July 5, 2024
(1)
Rate Determination
. Payment rates are the lowest of
(a) the eligible provider's usual and
			 customary charge to patients other than publicly aided individuals or
			 industrial accident patients;
(b)
			 the applicable listing from the schedule of allowable fees listed in
			 101 CMR 320.05;
			 or
(c) the amount that is allowable
			 under
			 42 U.S.C. §
										1396b(i)(7).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 320.00 - Rates for Clinical Laboratory Services › Section 320.06 - Filing and Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Required Reports
. Reporting requirements are governed
			 by
			 957
			 CMR 6.00:
Cost Reporting
			 Requirements
.
(2)
Penalty for Noncompliance
. The purchasing governmental
			 unit may impose a penalty in the amount of up to 15% of its payments to any
			 provider that fails to submit required information. The purchasing governmental
			 unit will notify the provider in advance of its intention to impose a penalty
			 under 101 CMR 320.06(2).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 320.00 - Rates for Clinical Laboratory Services › Section 320.07 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101
				CMR 320.00 are severable, and if any provision of
				101
				CMR 320.00 or application of such provision to any
				eligible clinical laboratory provider or any circumstances are held to be
				invalid or unconstitutional, such invalidity will not be construed to affect
				the validity or constitutionality of any remaining provisions to any eligible
				clinical laboratory providers or circumstances other than those held
				invalid.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 322.00 - Rates for Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment › Section 322.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
.
			 101 CMR
			 322.00 governs the determination of rates of payment
			 to be used by all governmental units in making payment to eligible providers of
			 durable medical equipment and supplies provided to publicly aided individuals.
			 The rates set forth in
			 101 CMR
			 322.00 do not apply to individuals covered by the
			 Workers' Compensation Act, M.G.L. c. 152. Rates for services rendered to such
			 individuals are set forth in 114.3 CMR 40.06:
Fees
.
(2)
Applicable Dates of Service
. Rates contained in
			 101 CMR
			 322.00 apply for dates of service provided on or after
			 July 7, 2023, unless otherwise specified.
(3)
Coverage
.
			 101 CMR
			 322.00 and the rates of payment contained herein apply
			 to the following categories:
(a) the purchase
			 or rental of durable medical equipment;
(b) the purchase of medical and surgical
			 supplies;
(c) the purchase or
			 rental of seating, positioning, mobility systems, and related
			 accessories;
(d) the purchase or
			 rental of prescribed oxygen delivery systems and respiratory therapy devices
			 and related supplies;
(e) the
			 purchase or rental of intravenous and enteral therapy, equipment, and related
			 supplies and services;
(f) the
			 repair or modification of the above listed types of equipment.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 322.00 - Rates for Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment › Section 322.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1) Purchase or
			 Rental of Durable Medical Equipment, Medical and Surgical Supplies. Payment to
			 an eligible provider for the purchase of the above services will be the lowest
			 of:
(a) the eligible provider's usual and
			 customary charge;
(b) the preferred
			 supplier rate published in an administrative bulletin pursuant to
			 101 CMR 322.01(7)
			  plus an additional percentage handling fee
			 if applicable;
(c) the rebate
			 agreement rate published in an administrative bulletin pursuant to
			 101 CMR
			 322.01(7); or
(d) such schedule of allowable fees set forth
			 in
			 101 CMR
			 322.06.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 322.00 - Rates for Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment › Section 322.04 - Filing and Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Required Reports
. Reporting requirements are governed
			 by 957 CMR
			 6.00:
Cost Reporting
			 Requirements
.
(2)
Penalty for Noncompliance
. The purchasing governmental
			 unit may impose a penalty in the amount of up to 15% of its payments to any
			 provider that fails to submit required information. The purchasing governmental
			 unit will notify the provider in advance of its intention to impose a penalty
			 under
			 101
			 CMR 322.04(2).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 322.00 - Rates for Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment › Section 322.07 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101 CMR
				322.00 are severable. If any provision of
				101 CMR
				322.00 or the application of any provision to the sale
				or rental of durable medical equipment, medical/surgical supplies, oxygen and
				respiratory therapy equipment should be held invalid or unconstitutional, such
				determination will not be construed to affect the validity or constitutionality
				of any other provision of
				101 CMR
				322.00 or the application of any other
				provision.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 323.00 - Rates for Hearing Services › Section 323.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
.
			 101 CMR
			 323.00 governs the payment rates to be used by all
			 governmental units and purchasers under M.G.L. c. 152 (the Workers'
			 Compensation Act) for hearing services provided to publicly aided individuals
			 and industrial accident patients.
(2)
Applicable Dates of
			 Service
. Rates contained in
			 101 CMR
			 323.00 apply for dates of service provided on or after
			 November 1, 2023.
(3)
Disclaimer of Authorization of Services
.
			 101 CMR
			 323.00 is not authorization for or approval of the
			 procedures for which rates are determined pursuant to
			 101 CMR
			 323.00. Governmental units and purchasers under M.G.L.
			 c. 152 that purchase care are responsible for the definition, authorization,
			 and approval of care and services extended to publicly aided individuals and
			 industrial accident patients.
(4)
Administrative Bulletins
. EOHHS may issue
			 administrative bulletins to clarify its policy on and understanding of
			 substantive provisions of
			 101 CMR
			 323.00 and to update billing codes in accordance with
			 101
			 CMR 323.01(5).
(5)
Coding Updates and
			 Corrections
. EOHHS may publish procedure code updates and
			 corrections in the form of an administrative bulletin. Updates may reference
			 coding systems including, but not limited to, the American Medical
			 Association's Current Procedural Terminology® (CPT) and Healthcare Common
			 Procedure Coding System (HCPCS). The publication of such updates and
			 corrections will list
(a) codes for which the
			 code numbers change, with the corresponding cross-references between new codes
			 and codes being replaced. Rates for such new codes are set at the rate of the
			 code that is being replaced;
(b)
			 codes for which the code number remains the same, but the description has
			 changed;
(c) deleted codes for
			 which there are no corresponding new codes; and
(d) codes for entirely new services that
			 require pricing. EOHHS will list these codes and apply individual consideration
			 (I.C.) payment for these codes until appropriate rates can be
			 developed.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 323.00 - Rates for Hearing Services › Section 323.03 - General Rate Provisions, Requirements, and Rates

Current through Register 1525, July 5, 2024
(1)
General Rate
			 Provisions
. Payment for the purchase of hearing aids and
			 authorized related accessories and services for the care and maintenance of
			 hearing aid instruments are the lowest of
(a)
			 the provider's usual charge to persons other than publicly aided individuals
			 and industrial accident patients;
(b) the provider's actual charge submitted;
			 or
(c) the schedule or maximum fees
			 listed in
			 101
			 CMR 323.03(5).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 323.00 - Rates for Hearing Services › Section 323.04 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Required Reports
. Reporting requirements are governed
			 by 957 CMR
			 6.00:
Cost Reporting
			 Requirements
.
(2)
Penalty for Noncompliance
. The purchasing governmental
			 unit may impose a penalty in the amount of up to 15% of its payments to any
			 provider that fails to submit required information. The purchasing governmental
			 unit will notify the provider in advance of its intention to impose a penalty
			 under
			 101
			 CMR 323.04(2).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 323.00 - Rates for Hearing Services › Section 323.05 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101 CMR
				323.00 are severable. If any provision of
				101 CMR
				323.00 or application of any provision to an
				applicable individual, entity, or circumstance is held invalid or
				unconstitutional, that holding will not be construed to affect the validity or
				constitutionality of any remaining provisions of
				101 CMR
				323.00 or application of those provisions to
				applicable individuals, entities, or circumstances.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 324.00 - Nonpublic Ambulance Service Reimbursement Trust Fund Assessment and Funding › Section 324.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
.
			 101 CMR
			 324.00 governs the Nonpublic Ambulance Service
			 Reimbursement Trust Fund assessment and funding.
(2)
Administrative
			 Bulletins
. EOHHS may issue administrative bulletins to clarify its
			 policy on and understanding of substantive provisions of
			 101 CMR
			 324.00.
(3)
Applicable Assessment
			 Period
. Assessment described in
			 101 CMR
			 324.00 is applicable for periods on or after July 1,
			 2021.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 324.00 - Nonpublic Ambulance Service Reimbursement Trust Fund Assessment and Funding › Section 324.02 - General Definitions

Current through Register 1525, July 5, 2024
As used in
				101 CMR
				324.00, terms have the meanings set forth in
				101
				CMR 324.02, except where the context clearly
				indicates otherwise.
Ambulance Service
. Ambulance service
				as defined in M.G.L. c. 111C, § 1.
Ambulance Service Cost Report
. The
				Ambulance Service Report of Costs, Revenues, and Statistics reported to the
				Center pursuant to
				957 CMR
				6.00:
Cost Reporting
				Requirements.
Center
. The Center for Health
				Information and Analysis established under M.G.L. c. 12C.
EOHHS.
The Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
Gross Patient Service Revenue (GPSR)
.
				The total dollar amount of nonpublic ambulance charges for services rendered in
				a provider's fiscal year.
Nonpublic Ambulance Provider
.
				Ambulance provider licensed pursuant to M.G.L. c. 111C, § 6 that is not a
				city or town, county, district, or other governmental body.
Nonpublic Emergency Ambulance Assessed
				Charges
. Massachusetts gross patient service revenue earned from
				all patients attributable to emergency ground ambulance service, less bad debt,
				charity care, or payer discounts. For each provider's fiscal year, assessed
				charges are determined using data reported in an ambulance provider's Cost
				Report for that fiscal year, or if that Cost Report is not submitted, using any
				alternative data available to EOHHS. EOHHS may reasonably calculate the portion
				of revenue attributable to emergency ground ambulance service, the allocation
				of bad debt, or any other element of the Nonpublic Emergency Ambulance Assesed
				Charges based on the data submitted by providers or other data possessed by
				EOHHS.
Trust Fund
. The Nonpublic Ambulance
				Service Reimbursement Trust Fund established under M.G.L. c. 29, § 2KKKKK,
				to provide money to be expended for Medicaid payments to nonpublic ambulance
				providers, as specified in
				101 CMR
				327.00:
Rates of Payment for Ambulance and
				Wheelchair Services.
The Secretary of EOHHS, as trustee, will
				administer the fund and will make expenditures from the fund consistent with
				M.G.L. c. 29, § 2KKKKK.
Uniform Assessment
. The percentage of
				nonpublic emergency ambulance assessed charges set by EOHHS as described in
				101
				CMR 324.04(1).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 324.00 - Nonpublic Ambulance Service Reimbursement Trust Fund Assessment and Funding › Section 324.03 - Sources and Uses of Fund

Current through Register 1525, July 5, 2024
(1)
General
. The Trust Fund includes
(a) an amount equal to all revenues generated
			 from the funds collected pursuant to
			 101 CMR
			 324.00;
(b) an amount equal to any federal financial
			 participation revenues claimed and received by the Commonwealth for eligible
			 expenditures made from the Trust Fund;
(c) any revenue from appropriations or other
			 money authorized by the general court and specifically designated to be
			 credited to the Trust Fund; and
(d)
			 interest earned on any money in the Trust Fund.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 324.00 - Nonpublic Ambulance Service Reimbursement Trust Fund Assessment and Funding › Section 324.05 - Filing and Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Accurate Data
. All reports, schedules, additional
			 information, books, and records that are filed or made available to EOHHS must
			 be certified under pains and penalties of perjury as true, correct, and
			 accurate by the chief executive officer, president, or chief financial officer
			 of the eligible nonpublic ambulance provider.
(2)
Examination of
			 Records
. Each eligible nonpublic ambulance provider must make
			 available all records relating to its operation and all records relating to a
			 holding company or any entity in which there may be a common ownership or
			 interrelated directorate upon request of EOHHS for examination.
(3)
Field Audits
.
			 EOHHS or its designee may conduct field audits of eligible nonpublic ambulance
			 providers to verify compliance with any aspect of
			 101 CMR
			 324.00.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 324.00 - Nonpublic Ambulance Service Reimbursement Trust Fund Assessment and Funding › Section 324.06 - Noncompliance

Current through Register 1525, July 5, 2024
(1)
Penalty for
			 Nonpayment
. If a nonpublic ambulance provider does not pay the
			 amount required pursuant to
			 101
			 CMR 324.04, or a specified portion thereof,
			 by the due date established by EOHHS, EOHHS may assess up to a 3% penalty on
			 the outstanding balance. EOHHS will calculate the penalty on the outstanding
			 balance as of the due date. EOHHS may assess up to an additional 3% penalty
			 against the outstanding balance and prior penalties for each month that a
			 nonpublic ambulance provider remains delinquent. EOHHS will credit partial
			 payments from delinquent nonpublic ambulance providers to the current
			 outstanding liability. If any amount remains from the partial payment, EOHHS
			 will then credit such amount to the penalty amount.
(2)
Penalty for Failure to Report
			 Nonpublic Emergency Ambulance Assessed Charges
. If a nonpublic
			 ambulance provider fails to report nonpublic emergency ambulance assessed
			 charges as required under
			 101
			 CMR 324.04(3)(a), EOHHS may
			 assess penalties consistent with
			 101
			 CMR 327.06:
Reporting and
			 Registration Requirements.
(3)
Penalty Amount
			 Determination
. In determining the penalty amount, EOHHS may
			 consider factors including, but not be limited to, the nonpublic ambulance
			 provider's payment history, financial situation, and relative share of the
			 payments.
(4)
Reduction
			 in Payment
. EOHHS may deny, reduce, or withhold payments that
			 would otherwise be made to an eligible nonpublic ambulance provider pursuant to
			 101 CMR
			 327.00:
Rates of Payment for Ambulance and
			 Wheelchair Van Services
if that nonpublic ambulance provider fails to
			 make full payment under
			 101
			 CMR 324.04 or is assessed penalties under
			 101
			 CMR 324.06(1). EOHHS will
			 notify the nonpublic ambulance provider of its intention to deny, reduce, or
			 withhold payment.
(5)
Successors in Interests or Providers under Common
			 Control
. EOHHS may apply all penalties and reductions in payments
			 to successor in interest to the nonpublic ambulance provider or any provider
			 under common interest.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 324.00 - Nonpublic Ambulance Service Reimbursement Trust Fund Assessment and Funding › Section 324.07 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101 CMR
				324.00 are severable. If any provision of
				101 CMR
				324.00 or the application of such provision of
				101 CMR
				324.00 is held invalid or unconstitutional, such
				determination will not be construed to affect the validity or constitutionality
				of any other provision of
				101 CMR
				324.00 or the application of any other
				provision.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 327.00 - Rates of Payment for Ambulance and Wheelchair Van Services › Section 327.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 101 CMR 327.00 governs the rates of
			 payment to eligible ambulance and wheelchair van service providers to be used
			 by all governmental units for services provided to publicly aided individuals.
			 The ground transport rates set forth in 101 CMR 327.00 also apply to
			 individuals covered by the Workers' Compensation Act, M.G.L. c. 152.
(2)
Applicable Dates of
			 Service
. Rates in 101 CMR 327.00 are applicable for dates of
			 service on or after September 29, 2023, except as otherwise noted.
(3)
Disclaimer of Authorization
			 of Services
. 101 CMR 327.00 is not authorization for or approval
			 of the services for which rates are determined pursuant to 101 CMR 327.00.
			 Governmental units that purchase services are responsible for the definition,
			 authorization, and approval of care and services provided to publicly aided
			 individuals.
(4)
Coverage
. The rates of payment in 101 CMR 327.00
			 constitute payment in full for all services provided by an eligible provider,
			 including administration and professional supervision services. The payment
			 rates will apply to ambulance and wheelchair van services provided by eligible
			 providers to publicly aided individuals whose medical condition requires the
			 use of such vehicles under the conditions described by the purchasing
			 governmental unit.
(5)
Exclusion
. 101 CMR 327.00 and the payment rates in
			 101
			 CMR 327.03 will not, under any conditions,
			 apply when the purchasing governmental unit determines that:
(a) no medical necessity exists; or
(b) some means of transportation other than
			 an ambulance or wheelchair van may be used without endangering the patient's
			 health; or
(c) ambulance or
			 wheelchair van usage is for an unauthorized purpose.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 327.00 - Rates of Payment for Ambulance and Wheelchair Van Services › Section 327.03 - General Rate Provisions and Payment

Current through Register 1525, July 5, 2024
(1)
Rate Determination
. The rates for authorized ambulance
			 and wheelchair van services under 101 CMR 327.00 are the lowest of:
(a) the eligible provider's usual fee to
			 patients other than publicly-aided individuals; or
(b) the eligible provider's actual charge
			 submitted; or
(c) the schedule of
			 fees set forth in
			 101
			 CMR 327.03.