reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.407 - Admission Criteria for Members 21 Years of Age or Older

Current through Register 1525, July 5, 2024
A member 21 years of age or older must meet all of the
				following conditions of medical necessity:
(A) demonstrate symptomatology consistent
			 with a diagnosis listed in the current edition of the DSM, and that such
			 symptomatology requires and will respond to therapeutic intervention;
(B) be cleared for treatment in a nonmedical,
			 nonsurgical treatment environment;
(C) require 24-hour medical, psychiatric, and
			 nursing services that can appropriately be provided only at an acute level of
			 hospital care;
(D) have a
			 psychiatric condition that results in serious dysfunction, such as increased
			 suicidal gestures, assaultiveness, or sudden inability to provide self-care,
			 that endangers the member or others; and
(E) present conditions that can reasonably be
			 expected to improve to the extent that psychiatric inpatient hospital services
			 will no longer be needed or further regression of the member's condition will
			 be prevented.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.408 - Payment Methodology

Current through Register 1525, July 5, 2024
(A)
In
			 State
. Payments to in-state private psychiatric inpatient
			 hospitals for services furnished to MassHealth members will equal the rate
			 established in the signed provider contract with the MassHealth
			 agency.
(B)
Out of
			 State
. Payment to out-of-state private psychiatric inpatient
			 hospitals will be the Massachusetts state-wide average
per diem
rate or administrative day rate established by the MassHealth agency
			 for in-state private psychiatric inpatient hospitals.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.409 - Nonreimbursable Services

Current through Register 1525, July 5, 2024
The following services are not reimbursable:
(A) drugs and durable medical equipment
			 prescribed for take-home use that are readily available from pharmacies or
			 medical providers;
(B) the cost of
			 any treatment or testing of a member or of a specimen from a member who is not
			 an inpatient in the psychiatric inpatient hospital;
(C) room-and-board services on the day of
			 discharge (unless the day of discharge is also the day of admission);
(D) leave-of-absence days;
(E) research or the provision of experimental
			 or unproven procedures;
(F) private
			 hospital rooms, except when medically necessary; and
(G) services furnished by the emergency room
			 or outpatient department on the day of admission, during the inpatient stay, or
			 on the day of discharge.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.410 - Service Limitations

Current through Register 1525, July 5, 2024
(A) Members younger
			 than 21 years old must be prescreened by a screening team or be admitted under
			 court order, pursuant to M.G.L. c. 123, §§ 7, 8, 12(a), and
			 12(b).
(B) Out-of-state psychiatric
			 inpatient hospital services are covered only as provided in
			 130 CMR
			 450.109:
Out-of-state
			 Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.411 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				psychiatric inpatient hospital services for EPSDT-eligible members in
				accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnosis and Treatment (EPSDT) Services:
				Introduction.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.412 - Child and Adolescent Needs and Strengths (CANS) Certification

Current through Register 1525, July 5, 2024
The following clinicians are eligible to administer the Child
				and Adolescent Needs and Strengths (CANS) in psychiatric inpatient hospitals
				and must be certified every two years, according to the process established by
				the Executive Office of Health and Human Services (EOHHS):
(A) psychiatrists and psychiatric
			 residents;
(B) Child/Adolescent or
			 Adult Psychiatric-mental Health Clinical Nurse Specialist-board Certified
			 (PMHCNS-BC) or Psychiatric Mental Health Nurse Practitioner-board Certified
			 (PMHNP-BC);
(C) psychologists who
			 have a specialization in clinical or counseling psychology;
(D) social workers who have a master's degree
			 in social work from an accredited educational institution; and
(E) counselors who have a master's degree in
			 counseling education, counseling psychology, or rehabilitation psychology from
			 an accredited educational institution.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.413 - Child and Adolescent Needs and Strengths (CANS) Data Reporting

Current through Register 1525, July 5, 2024
For each Child and Adolescent Needs and Strengths (CANS)
				conducted, the hospital must report data collected during the assessment to the
				MassHealth agency, in the manner and format specified by the MassHealth
				agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.415 - Notification and Right of Appeal

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency or its agent will send a written notification of approval or
			 denial to the member and to the medical practitioner or facility who submitted
			 the request for psychiatric inpatient hospital services. If authorization for
			 psychiatric inpatient hospital services is denied, the notification will inform
			 the member and the medical practitioner or facility of the reason for the
			 denial, the member's right to appeal, and the appeal process.
(B) Following the decision of the MassHealth
			 agency or its agent to deny services in a psychiatric inpatient hospital, a
			 member may appeal by requesting a fair hearing from the MassHealth agency. The
			 request for a fair hearing must be made, in writing, within 30 days after
			 receipt of the notice of the denial. The appeal procedure and fair hearing will
			 be administered and conducted by the Board of Hearings in accordance with
			 130 CMR 610.000:
MassHealth: Fair Hearing Rules.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.416 - Treatment Plan

Current through Register 1525, July 5, 2024
(A) The hospital
			 multidisciplinary treatment team must develop and implement a written treatment
			 plan for each member. For members younger than 21 years old, the treatment plan
			 must be developed in conjunction with any case managers the member may have
			 from DMH, DCF, DYS, or DDS. The treatment plan must
(1) be developed and reviewed with the
			 fullest possible participation of the member, his or her designated
			 representative or guardian, if any, and individuals in whose care the member
			 will be released after discharge;
(2) be based on the findings of an initial
			 assessment;
(3) be based on a
			 diagnostic evaluation that includes examination of the medical, psychological,
			 social, behavioral, and developmental aspects of the member's situation and
			 that reflects the need for psychiatric inpatient hospital care;
(4) state long- and short-range
			 goals;
(5) state, with specific and
			 measurable terms and time frames, treatment objectives that include changes
			 that must occur in order to discharge the patient;
(6) prescribe an integrated program of
			 therapies, activities, and experiences designed to meet the treatment
			 objectives;
(7) specifically
			 identify the psychiatric symptoms that require psychiatric inpatient hospital
			 care rather than treatment in a less-restrictive setting;
(8) be developed and implemented within three
			 calendar days of admission;
(9)
			 include an initial determination of the member's expected length of stay in the
			 facility and the anticipated discharge plan, that is coordinated with
			 outpatient and community providers;
(10) include written documentation in the
			 member's record that the member, his or her legal guardian, and family members
			 are given the opportunity to participate in the development and modification of
			 the treatment plan and the psychiatric treatment itself, through participation
			 in family therapy as clinically indicated, and to attend treatment plan
			 meetings as clinically appropriate and according to the bounds of consent;
			 and
(11) when appropriate, include
			 indications of the need for DMH Continuing Care Services or for services from
			 other state agencies, or both.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.417 - Conditions for Continuing Care

Current through Register 1525, July 5, 2024
(A) To continue
			 to qualify for psychiatric inpatient hospital services, members must continue
			 to meet the admission criteria described in
			 130 CMR
			 425.406 or
			 425.407,
			 whichever is applicable, or meet one of the conditions in 130 CMR 425.417(B).
			 Members who are younger than 21 years old must also be reviewed by a screening
			 team prior to the 30th day after admission and every
			 30 days thereafter.
(B)
Additional Conditions
. The following additional
			 conditions qualify a member 21 years of age or older to continue to receive
			 psychiatric inpatient hospital services, even if the member does not qualify
			 under 130 CMR 425.417(A):
(1) the persistence
			 of conditions that necessitated admission, despite therapeutic efforts, or the
			 emergence of additional problems consistent with the admissions criteria in
			 130 CMR
			 425.406 or
			 425.407;
(2) a severe reaction to medication;
			 or
(3) a need for stabilization of
			 psychiatric conditions, integration of gains, or preparation for transition to
			 outpatient care or a residential setting.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.420 - Reimbursable Administrative Days

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency pays a private psychiatric inpatient hospital for a continued
			 length of stay of up to 30 administrative days, as defined in
			 130 CMR 425.402. For
			 members younger than 21 years old and members 65 years of age or older, the
			 MassHealth agency may pay a private psychiatric inpatient hospital for
			 administrative days exceeding the 30-day limit where the hospital can
			 demonstrate, to the satisfaction of the MassHealth agency or its agent, that
			 the hospital has
(1) experienced
			 extraordinary difficulty in placing the member, including the specific reasons
			 for such extraordinary difficulty; and
(2) exhaustively explored all potential
			 appropriate placements.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.421 - Nonreimbursable Administrative Days

Current through Register 1525, July 5, 2024
Administrative days are not reimbursable when
(A) an appropriate placement is currently
			 available, but the hospital has not transferred or discharged the member
			 because of the hospital's administrative or operational delays;
(B) the MassHealth agency or its agent
			 determines that appropriate noninstitutional or institutional placement or
			 services are available within a reasonable distance of the member's
			 noninstitutional (customary) residence and the member, the member's family, or
			 any person legally responsible for the member refuses the placement or
			 services; or
(C) the MassHealth
			 agency or its agent determines that appropriate noninstitutional or
			 institutional placement or services are available within a reasonable distance
			 of the member's noninstitutional (customary) residence and advises the hospital
			 of the determination, and the hospital or the physician refuses or neglects to
			 discharge the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.423 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) A record must be
			 established and maintained for each member that is consistent with current
			 professional standards. The record must include the following documents, if
			 applicable:
(1) the screening certification
			 from a screening team, as described in
			 130 CMR
			 425.406, or appropriate court documentation
			 for court-ordered admissions, pursuant to M.G.L. c. 123, §§ 7, 8,
			 12a, and 12b;
(2) the treatment
			 plan, as described in
			 130 CMR
			 425.416;
(3) documentation from the hospital
			 interdisciplinary review team supporting the need for continuing care, as
			 described in
			 130 CMR
			 425.417;
(4) the discharge plan, as described in
			 130 CMR
			 425.418; and
(5) for members younger than 21 years old, a
			 copy of the CANS completed during the discharge planning
			 process.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.424 - Confidentiality

Current through Register 1525, July 5, 2024
(A) Psychiatric inpatient hospitals must
			 comply with all state and federal laws and regulations relating to
			 confidentiality and privacy.
(B) At
			 all times, psychiatric inpatient hospitals must recognize the MassHealth
			 agency's ownership of personal data (as defined in M.G.L. c. 66A, § 1) and
			 other information deemed confidential by the Commonwealth.
(C) If any employee or subcontractor of a
			 psychiatric inpatient hospital is involved with a member's personal data or
			 other confidential information, the psychiatric inpatient hospital must inform
			 the employee or subcontractor of the laws and regulations relating to
			 confidentiality.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				426.000 governs services provided by audiologists
				under MassHealth. An independent audiologist who is licensed and certified in
				accordance with
				130 CMR
				426.404 and engages in the practice of
				audiology is eligible to become a provider in MassHealth. All audiologists
				participating in MassHealth must comply with MassHealth regulations, including
				but not limited to those set forth in
				130 CMR
				426.000 and
				450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency covers audiological services only
			 when provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in the MassHealth regulations. MassHealth regulations at
			 130 CMR 450.105:
Coverage Types
specifically state, 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 426.000 - Audiologist Manual › Section 426.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
In-state
. The following requirements apply when the
			 audiology practice is located in Massachusetts.
(1)
Independent
			 Audiologist
. An independent audiologist engaged in private
			 practice in Massachusetts is eligible to participate in MassHealth only if the
			 individual is licensed as an audiologist by the Commonwealth of Massachusetts,
			 Division of Professional Licensure, Board of Registration in Speech-Language
			 Pathology and Audiology.
(2)
Acute Hospital Outpatient Department, Hospital-licensed Health
			 Center, or Other Satellite Clinic
. An acute hospital's outpatient
			 department, hospital-licensed health center, or other satellite clinic that
			 participates in MassHealth pursuant to the Executive Office of Health and Human
			 Services (EOHHS) Acute Hospital Request for Applications (RFA) and contract is
			 eligible to provide services designated as hearing aid services in Subchapter 6
			 of the MassHealth
Audiologist Manual
for providers under
			 130 CMR
			 426.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.405 - Out-of-state Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays out-of-state audiologists in
				accordance with
				130 CMR
				450.109:
Out-of-state
				Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.406 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The MassHealth agency pays the lower of the following for
				audiological services, hearing aids, and related services:
(A) the audiologist's usual and customary
			 fee; or
(B) the maximum fee listed
			 in the applicable fee schedule of the Massachusetts Division of Health Care
			 Finance and Policy.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.407 - Individual Consideration

Current through Register 1525, July 5, 2024
Services designated "I.C." in the list of service codes and
				descriptions in Subchapter 6 of the
Audiologist Manual
are
				given individual consideration by the MassHealth agency to determine the amount
				of payment to be made to the audiologist. The MassHealth agency determines the
				amount of payment using the following criteria:
(A) the time required to perform the
			 procedure;
(B) the degree of skill
			 required to perform the procedure;
(C) the severity or complexity of the
			 member's hearing disorder or disability;
(D) the policies, procedures, and practices
			 of other third-party purchasers of health care; and
(E) the reasonable and customary practices of
			 audiologists.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.408 - Prior Authorization

Current through Register 1525, July 5, 2024
Services designated "P.A." in the list of service codes and
				descriptions in Subchapter 6 of the
Audiologist Manual
require
				prior authorization from the MassHealth agency.
(A) The MassHealth agency requires prior
			 authorization for
(1) any hearing aid that
			 costs more than the amount indicated in the applicable service description in
			 Subchapter 6 of the
Audiologist Manual
;
(2) the replacement of a hearing aid,
			 regardless of the cost of the hearing aid, due to
(a) a medical change;
(b) loss of the hearing aid; or
(c) damage beyond repair to the hearing
			 aid;
(3) certain hearing
			 aid related services as specified in Subchapter 6 of the
Audiologist
			 Manual
; and
(4) any
			 replacement of cochlear implant external components.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.409 - Separate Procedures

Current through Register 1525, July 5, 2024
Some procedures are commonly carried out as an integral part of
				a total service, and as such do not warrant a separate identification. When,
				however, such a procedure is performed independently of, and is not immediately
				related to, other services, it is designated as a "separate procedure" or
				"S.P." in the list of service codes and descriptions in Subchapter 6 of the
Audiologist Manual
. Thus, when a procedure is performed alone
				for a specific purpose, it must be considered a separate
				procedure.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.410 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				audiologist services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnosis and Treatment (EPSDT) Services: Introduction
,
				without regard to service limitations described in
				130 CMR
				426.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.414 - Dispensing Requirements

Current through Register 1525, July 5, 2024
An audiologist may dispense a hearing aid only after receiving
				the following documentation.
(A)
Complete Audiological Evaluation
. A complete
			 audiological evaluation includes air and bone conduction, spondee thresholds,
			 and word discrimination testing.
(1) The
			 audiologist must have personally completed or received a complete audiological
			 evaluation performed by one of the following:
(a) an independent audiologist who personally
			 performed and completed the audiological evaluation;
(b) a licensed audiologist who is employed at
			 a speech and hearing clinic and who personally performed and completed the
			 audiological evaluation; or
(c) a
			 licensed audiologist who is employed by a physician, or by an acute hospital's
			 outpatient department, hospital-licensed health center or other satellite
			 clinic; or
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.416 - Reimbursable Services

Current through Register 1525, July 5, 2024
(A)
Complete Audiological Evaluation
.
(1) Payment for a complete audiological
			 evaluation will be made only if the evaluation is recommended by a
			 physician;
(2)
Two
			 Audiologists
. The MassHealth agency will pay for two audiologists
			 working together to perform an evaluation of an individual member under those
			 circumstances where the knowledge, skills, and experience of the primary
			 audiologist have identified a need for a second audiologist to aid in
			 completing the initial test battery, such as for the testing of very young
			 children or those with other pertinent developmental, physical, cognitive, or
			 maturational factors. Circumstances warranting the services of two audiologists
			 must be fully documented in the member's medical record. To receive full
			 payment, both audiologists must use the appropriate service code and modifier
			 combination listed in Subchapter 6 of the
Audiologist Manual
.
			 The MassHealth agency pays one-half of the total reimbursement for two
			 audiologists to each individual provider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.417 - Nonreimbursable Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for any of the following
				services:
(A) the rental of hearing
			 aids;
(B) hearing aids that are
			 completely in the ear canal (CIC);
(C) personal FM systems; or
(D) assistive technology devices provided
			 under
			 34 CFR
			 300.308, where such devices are maintained at
			 the school facility for the general use of disabled students, and assistive
			 technology services provided under
			 34 CFR
			 300.308 relating to the use of such
			 devices.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.418 - Service Limitations

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency does not pay for more than one hearing aid per ear per member in a
			 60-month period without prior authorization in accordance with
			 130 CMR
			 426.408. One hearing aid per ear consists of
			 either one binaural hearing-aid fitting, or two monaural hearing aids dispensed
			 more than six months apart, with one dispensed for the left ear and the other
			 dispensed for the right ear.
(B)
			 Two monaural fittings dispensed within a six-month period, with one aid
			 dispensed for the left ear and the other for the right ear, are defined as a
			 single binaural fitting. The MassHealth agency does not pay for two monaural
			 dispensing fees for this service. MassHealth pays only one binaural dispensing
			 fee for this service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 426.000 - Audiologist Manual › Section 426.419 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
An audiologist must maintain a medical record for each member
				for a period of at least as long as the minimum period required by
				130 CMR
				450.205(G). The MassHealth
				agency does not pay a provider for services if the provider does not have
				adequate documentation to substantiate the provision of services payable under
				MassHealth. The medical record must contain all pertinent information about the
				services provided, including the date of service and the dates on which
				materials were ordered and dispensed. In no instance does the completion of the
				appropriate MassHealth claim form, the maintenance of a copy of such a claim,
				or the simple notation of service codes constitute sufficient documentation for
				the purposes of 130 CMR 426.419. The recordkeeping requirements are specific to
				each type of service and are described as follows.
(A)
Cochlear Implant External
			 Components
. The audiologist must maintain the following
			 information in the member's medical record:
(1) A history of the member's hearing loss
			 and use of the cochlear implant. The history must contain the following
			 information:
(a) the make, model number, type,
			 and date of purchase of the cochlear implant external components;
(b) a description of any speech and hearing
			 therapy received by the member; and
(c) a description of any medical condition
			 that the member has that may impair vision or affect cochlear implant
			 use.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				427.000 establishes the requirements and procedures
				for the purchase, rental, and repair of oxygen and respiratory therapy
				equipment and supplies under the Medical Assistance Program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				427.000 have the meanings given in
				130
				CMR 427.402 unless the context clearly
				requires a different meaning.
Accessory Equipment
- a product
				fabricated primarily and customarily to modify or enhance the usefulness or
				functional capability of other equipment and that is generally useful only in
				the presence of other equipment.
Apnea Monitor
- a device that has the
				ability to recognize central or mixed apneas and bradycardia as they occur and
				to record these events for subsequent review. It must:
(1) have alarms that accurately reflect the
			 predisposing condition and that consistently alert and are understandable to
			 the caregiver;
(2) be capable of
			 monitoring its own internal essential functions to assure proper
			 operation;
(3) be noninvasive;
			 and
(4) be easy to use and
			 understand.
Adjusted Acquisition Cost
- the price
				paid to a supplier by a provider for oxygen and respiratory therapy equipment,
				excluding all associated costs such as, but not limited to, shipping, handling,
				and insurance costs.
Customized Equipment
- durable medical
				equipment that is made or adapted to meet the specific needs of a particular
				patient and that is sufficiently specialized or modified to preclude the use of
				such equipment by subsequent patients. Customized equipment may be either
				custom fabricated or custom fitted.
(1)
custom
			 fabricated
- equipment made for a patient from measurement or
			 patterns, or both. The following list describes various types of
			 custom-fabricated equipment:
(a)
casting
- encasing a body part in a cast;
(b)
molded to patient
			 model
- equipment that is fabricated from a positive mold
			 developed from a plaster cast taken of the involved portion of the patient's
			 body;
(c)
non-molded
- no casting or molding techniques are used
			 in the fabrication of the equipment, which may be either a stock item or made
			 from measurement or patterns, or both.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. MassHealth covers oxygen and
			 respiratory therapy equipment provided to eligible MassHealth members, subject
			 to the restrictions and limitations described in
			 130 CMR
			 427.000 and
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
.
			 130CMR 450.105:
Coverage Types
specifically states, for each coverage type,
			 which services are covered and which members are eligible to receive those
			 services.
(B)
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
.
(C)
Verification of Member
			 Eligibility
. For information about verifying member eligibility
			 and coverage type,
see
130
			 CMR 450.107:
Eligible Members and the
			 MassHealth Card
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
Participating Provider Requirement
. Payment for the
			 services described in
			 130 CMR
			 427.000 is made to oxygen and respiratory therapy
			 equipment providers and repair service providers who are participating in
			 MassHealth; to providers also enrolled as MassHealth participating durable
			 medical equipment and supplies (DME) providers, orthotic services providers, or
			 prosthetic services providers who meet all program-specific requirements; and
			 to MassHealth-enrolled pharmacy providers who have been assigned an oxygen and
			 respiratory therapy equipment specialty in accordance with
			 130
			 CMR 427.404(B).
			 Participating oxygen and respiratory therapy equipment providers must be
			 accredited by an accrediting body that is acceptable to the Centers for
			 Medicare & Medicaid Services. Applicants must meet the requirements in
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
, as well as the requirements in
			 130 CMR
			 427.000. Participating oxygen and respiratory therapy
			 equipment providers must continue to meet provider eligibility participation
			 requirements throughout the period of their provider contract with the
			 MassHealth agency.
(B)
Pharmacy Providers Assigned Oxygen and Respiratory Therapy
			 Equipment Specialty
. Applicants or providers enrolled as a
			 MassHealth pharmacy provider under
			 130 CMR
			 406.000:
Pharmacy Services
may
			 qualify to provide oxygen and respiratory therapy equipment services if the
			 following conditions are met:
(1) the
			 applicant or provider meets all other conditions under
			 130 CMR
			 427.000 to provide oxygen and respiratory therapy
			 equipment and supplies; and
(2) the
			 MassHealth agency has assigned a specialty of oxygen and respiratory therapy
			 equipment to the applicant's or provider's existing provider number for
			 pharmacy services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.405 - Services Provided by Out-of-State Providers

Current through Register 1525, July 5, 2024
The Division pays for services provided in another state to the
				same extent that it pays for services within its boundaries if the services are
				provided to a recipient who is a resident of Massachusetts and any of the
				following conditions are met:
(A)
			 services are needed because of a medical emergency;
(B) services are needed and the recipient's
			 health would be endangered if the recipient were required to travel to the
			 Commonwealth;
(C) the Division
			 determines, on the basis of medical advice, that the needed services, or
			 necessary supplementary resources, are more readily available in another state;
			 or
(D) the recipient lives in an
			 area of Massachusetts that borders another state, and it is a general practice
			 of recipients in that area to use medical resources in the adjacent
			 state.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.406 - Reimbursable Services

Current through Register 1525, July 5, 2024
The Division pays for the purchase, rental, and repair of
				oxygen and respiratory therapy equipment and supplies subject to the
				restrictions and limitations in
				130 CMR
				427.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.407 - Nonreimbursable Services

Current through Register 1525, July 5, 2024
The Division does not pay for the following equipment and
				services:
(A) any equipment or services
			 that are investigative or experimental in nature;
(B) any equipment or services for which,
			 under comparable circumstances, the provider does not customarily bill private
			 patients who do not have health insurance;
(C) nonmedical equipment or supplies.
			 Equipment that is used primarily and customarily for a nonmedical purpose is
			 not considered medical equipment, even if such equipment has a medically
			 related use. For example, equipment whose primary function is environmental
			 control, comfort, or convenience is not reimbursable;
(D) any equipment or services that are not
			 both necessary and reasonable for the treatment of a recipient's pulmonary
			 condition. This includes but is not limited to:
(1) equipment or services that cannot, based
			 on medical standards as determined by the Division, reasonably be expected to
			 make a meaningful contribution to the treatment of a recipient's pulmonary
			 condition;
(2) equipment or
			 services that are substantially more costly than a medically appropriate and
			 feasible alternative; and
(3)
			 equipment or services that serve essentially the same purpose as equipment
			 already available to the recipient;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.408 - Prescription Requirements

Current through Register 1525, July 5, 2024
(A) The purchase or
			 rental of any equipment or services described in
			 130 CMR 427.000 is
			 reimbursable only after the provider has obtained a written prescription signed
			 by a licensed physician or independent nurse practitioner. The prescription
			 must be dated within 90 days of the initial date of service and include the
			 following information:
(1) the recipient's
			 name, address, and recipient identification number (RID);
(2) the oxygen and respiratory equipment
			 requested;
(3) the diagnosis
			 associated with the prescribed therapy;
(4) specific therapeutic
			 objectives;
(5) for oxygen therapy
			 equipment, the liter flow and hours per day;
(6) for respiratory therapy equipment, the
			 frequency of use per day;
(7) the
			 estimated length of time that the equipment will be used by the
			 recipient;
(8) the prescriber's
			 address and telephone number; and
(9) the date the prescription was signed by
			 the prescriber.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.409 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) The Division
			 requires that the provider obtain prior authorization as a prerequisite to
			 payment for the oxygen and respiratory therapy equipment and services listed in
			 130 CMR
			 427.410 and
			 427.411,
			 except as specified in
			 130 CMR
			 427.427(B). Prior
			 authorization determines only the medical necessity of the authorized item or
			 service and does not waive any other prerequisites to payment such as recipient
			 eligibility or resort to health insurance payment.
(B) Providers must submit requests for prior
			 authorization in accordance with the instructions in Subchapter 5 of the
Oxygen and Respiratory Therapy Equipment Manual
. Before
			 determining the medical necessity of an itemor service for which prior
			 authorization is requested, the Division may, at its discretion, require the
			 prescriber to submit an assessment of the recipient's pulmonary disability and
			 to describe the specific therapeutic goals of the requested service.
(C) For each item requested, the
			 prior-authorization request must include an invoice that reflects the
			 provider's adjusted acquisition cost as described in
			 130 CMR
			 427.420. The invoice must be placed in the
			 recipient's record and made available to the Division pursuant to
			 130 CMR
			 427.430.
(D) The provider must submit the
			 prior-authorization request within 90 days of the requested date of service
			 (date of delivery). Failure to submit the request within this 90-day period
			 will result in denial of the request.
(E) The Division will send written
			 notification of the prior authorization decision to the recipient and the
			 provider. The notification will indicate approval, deferral because additional
			 information is necessary, modification, ordenial. Notification of denial will
			 include the reason for denial. The recipient, the provider, and the prescriber
			 have the right to resubmit a request and furnish additional information. The
			 recipient may appeal the denial of a prior-authorization request within 30 days
			 after the date of the notice of denial. Procedures for such an appeal are set
			 forth in
			 130 CMR 610.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.410 - Purchases Requiring Prior Authorization

Current through Register 1525, July 5, 2024
The purchase of any of the following requires prior
				authorization:
(A) oxygen or
			 respiratory therapy equipment costing more than $35.00;
(B) gaseous or liquid oxygen; and
(C) repair services costing more than
			 $35.00.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.411 - Rentals Requiring Prior Authorization

Current through Register 1525, July 5, 2024
The rental of any of the following requires prior
				authorization:
(A) oxygen or
			 respiratory therapy delivery systems;
(B) suction apparatus;
(C) nebulizers;
(D) intermittent positive pressure breathing
			 (IPPB) machines; and
(E) equipment
			 that is not listed as a rental item in Subchapter 6 of the
Oxygen and
			 Respiratory Therapy Equipment Manual.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.420 - Adjusted Acquisition Cost

Current through Register 1525, July 5, 2024
(A) The adjusted
			 acquisition cost must not exceed the manufacturer's current catalog (list)
			 price and must be evidenced by the purchase price of the equipment listed on a
			 copy of a receipted invoice from the seller.
(B) Any additional discounts must be properly
			 disclosed and appropriately reflected in the cost claimed or charges made by
			 the provider pursuant to M.G.L. c. 118E, § 41, and U.S.C. §
			 1320a-7b(b)(3)(A).
(C) If the
			 equipment has not been purchased by the provider at the time of the
			 prior-authorization request, a quote reflecting the absolute lowest price of
			 the item and the catalog (list) price may be substituted for the receipted
			 invoice. The quotation shall be on the manufacturer's letterhead or form and be
			 addressed to the provider.
(D) The
			 actual receipted invoice must be placed in the recipient's records. This record
			 shall be maintained and available to the Division pursuant to
			 130 CMR
			 427.430.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.421 - Rates of Payment

Current through Register 1525, July 5, 2024
The Massachusetts Division of Health Care Finance and Policy
				determines the maximum allowable fees for oxygen and respiratory therapy
				equipment. Payment is always subject to the conditions, exclusions, and
				limitations set forth in
				130 CMR
				427.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.422 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) Some services
			 listed in Subchapter 6 of the
Oxygen and Respiratory Therapy Equipment
			 Manual
are designated "I.C," an abbreviation for individual
			 consideration. Individual consideration means that a fee could not be
			 established by the Division of Health Care Finance and Policy. The payment for
			 an individual-consideration service will be determined by the Division's
			 professional advisors. Before making a determination, the
			 Division'sprofessional advisors will analyze the provider's report of services
			 submitted, the cost of constructing or adapting the device, and the adjusted
			 acquisition cost of the materials.
(B) Providers must maintain adequate records
			 to determine the appropriateness of individual-consideration claims and must
			 provide these documents to the Division upon demand. Payment to a provider for
			 an individual-consideration claim shall be in accordance with
			 130 CMR 427.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.423 - Purchase of Oxygen and Respiratory Therapy Equipment

Current through Register 1525, July 5, 2024
(A) Payment to a provider for the purchase of
			 oxygen and respiratory therapy equipment shall be the lowest of:
(1) the provider's usual and customary charge
			 to the general public;
(2) the
			 adjusted acquisition cost of the item plus a markup not to exceed:
(a) 50% for any item whose adjusted
			 acquisition cost is less than $25;
(b) 45% for any item whose adjusted
			 acquisition cost is $25 or greater and less than $100;
(c) 40% for any itemwhose adjusted
			 acquisition cost is $100 or greater and less than $200;
(d) 35% for any item whose adjusted
			 acquisition cost is $200 or greater and less than $300; or
(e) 30% for any item whose adjusted
			 acquisition cost is $300 or greater; and
(3) the fee set forth in the applicable fee
			 schedule of the Division of Health Care Finance and Policy.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.424 - Rental of Oxygen and Respiratory Therapy Equipment

Current through Register 1525, July 5, 2024
(A) The monthly rental payment to a provider
			 for respiratory therapy equipment shall be the lowest of:
(1) 1/6 of the adjusted acquisition cost of
			 the equipment for the first six months and 1/12 of the adjusted acquisition
			 cost of the equipment for each month after the first six months;
(2) the provider's usual and customary rental
			 charge to the general public for one month; or
(3) the fee set forth in the applicable fee
			 schedule of the Division of Health Care Finance and Policy.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.425 - Purchase of Oxygen and Respiratory Therapy Equipment Rented by the Division

Current through Register 1525, July 5, 2024
The Division at its discretion may purchase, at the following
				rates of payment, oxygen and respiratory therapy equipment that is being
				provided on a monthly rental basis.
(A) If the Division exercises the option to
			 purchase the equipment within three months from the date of delivery of the
			 equipment, 70% of the total rental payments shall be applied toward the maximum
			 allowable purchase price computed in accordance with
			 130 CMR
			 427.423(A) and
			 (B).
(B) If the Division exercises the option to
			 purchase the equipment any time after three months from the date of delivery of
			 the equipment, 70% of the first three monthly rental payments and 50% of all
			 subsequent monthly rental payments shall be applied toward the maximum
			 allowable purchase price computed in accordance with
			 130 CMR
			 427.423(A) and
			 (B).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment › Section 427.426 - Repair of Oxygen and Respiratory Therapy Equipment Purchased by the Division

Current through Register 1525, July 5, 2024
(A) Prior
			 authorization is required for all repair services costing more than $35. Prior
			 authorization requests for repair services must be submitted in accordance with
			 the instructions in Subchapter 5 of the
Oxygen and Respiratory Therapy
			 Equipment Manual
.
(B) All
			 claims for repair services costing $35 or less must be accompanied by a service
			 report written on the provider's business stationary. The report must include
			 the following information:
(1) the name of the
			 person who requested the service and the date of the request;
(2) a specific description of the equipment
			 malfunction that was repaired;
(3)
			 a list of procedures and parts furnished to complete the repair; and
(4) the cost of each procedure and part
			 furnished and the time required to complete the repair.