Code of Massachusetts Regulations
101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES
Title 101 CMR 613.00 - Health Safety Net Eligible Services
Section 613.03 - Eligible Services Requirements
Universal Citation: 101 MA Code of Regs 101.613
Current through Register 1531, September 27, 2024
(1) General. To qualify as a service eligible for payment, the service must meet the following criteria.
(a)
Eligible Services
Categories. There are three categories of services eligible for
payment from the Health Safety Net, as follows:
1. Reimbursable Health Services to Low Income
Patients as defined in
101 CMR
613.04;
2. Medical Hardship, pursuant to the
requirements in
101 CMR 613.05;
and
3. Bad Debt, pursuant to the
requirements in
101 CMR
613.06.
(b)
Eligible Services Limitations
- General. The Health Safety Net does not pay for, and Providers
may not submit claims to the Office for, services that are not medically
necessary or for which another public or private payer is responsible. The
Health Safety Net is the payer of last resort.
1. The Health Safety Net Office may request,
and the Provider must provide, any and all medical records (or clear
photocopies of such records) corresponding to or documenting the services
claimed upon request of the Health Safety Net Office or its agent.
2. The medical record must contain sufficient
data to document fully the nature, extent, quality, and necessity of the care
provided to a Patient for each service claimed for payment.
3. For services for which MassHealth requires
prior authorization, the Provider must ensure that current clinical standards
are used to determine whether the service is medically necessary. The Health
Safety Net Office or its agent may audit claims to verify medical
necessity.
4. All Providers must
make diligent efforts to obtain payment first from other resources, including
personal injury protection (PIP) payments, to ensure that the Health Safety Net
is the payer of last resort.
5. If
the Health Safety Net Office, or its agent, identifies a third-party resource
after the Provider has billed and received payment from the Health Safety Net,
it will notify the Provider of this available third-party resource. Upon
receipt of notification, the Provider must remit the Health Safety Net payment
or provide documentation of diligent efforts as described in 101 CMR
613.03(1)(c)3. to obtain payment from the third-party resource. The Office, or
its agent, will review the submitted documentation to determine whether the
Provider made diligent efforts. If the Office, or its agent, determines the
Provider did not make diligent efforts to receive payment from the third party,
the Health Safety Net may recover the payment by deducting it from future
payments.
6. If the Office, or its
agent, identifies a third-party resource, the Office may recover from the
financially responsible third party the costs attributable to services provided
to an individual that were paid by the Health Safety Net. A payment from the
Health Safety Net for such services is recoverable from the third party and the
payment, after notice to the third party, operates as a lien under M.G.L. c.
118E.
(c)
Reimbursable Health Services Limitations - Low Income
Patients.
1. For insured Low
Income Patients, the Health Safety Net does not pay for, and Providers may not
submit claims for, services for which the primary insurer has denied payment
because of a technical billing error, because the Patient obtained out of
network services, because the Patient failed to obtain required prior
authorization for services, or because of other administrative reasons. The
Health Safety Net does not pay claims for the balance of an insurer's
contractual allowance or for late charges for a service that has been paid by
another payer.
2. For insured Low
Income Patients with other available resources including, but not limited to,
private health and casualty insurance, the Health Safety Net
a. does not pay a Provider if it determines
that, among other things, the Provider has not made diligent efforts to obtain
payment from those resources; and
b. recovers any payments made if it
determines that the Provider has not made diligent efforts to obtain payment
from those resources.
3.
"Diligent efforts" is defined as making every effort to identify and obtain
payment from all other liable parties, including insurers. Diligent efforts
include, but are not limited to
a.
determining the existence of insurance that could pay for medical expenses by
asking the Patient if he or she has other insurance and by using insurance
databases available to the Provider. In the event of a motor vehicle accident,
this includes investigating whether the Patient, driver, and/or owner of any
motor vehicle involved had a motor vehicle liability policy;
b. verifying the Patient's other health
insurance coverage, currently known to the Health Safety Net, through EVS, or
any other health insurance resource available to the Provider, on each date of
service and at the time of billing;
c. submitting claims to all insurers with the
insurer's designated service code for the service provided;
d. complying with the insurer's billing and
authorization requirements;
e.
appealing a denied claim when the service is payable in whole or in part by an
insurer; and
f. immediately
returning any payment received from the Office when any available third-party
resource has been identified.
4. For insured Low Income Patients with
private insurance, including Student Health Plans and Qualified Health Plans
other than the Premium Assistance Payment Program Operated by the Health
Connector, the Health Safety Net pays only for deductibles, coinsurance, and
Reimbursable Health Services not covered by the insurer. The Health Safety Net
does not pay for copayments required by a private insurer.
5. For MassHealth members enrolled in
MassHealth Limited, EAEDC, CMSP, CMSP plus Limited, and for MassHealth Family
Assistance - Children, the Health Safety Net pays only for Reimbursable Health
Services not covered by the member's MassHealth benefit. A Provider may submit
a claim for Reimbursable Health Services not covered by EAEDC only if the
member's EAEDC eligibility is non-temporary. A Provider may submit a claim for
Reimbursable Health Services not covered by CMSP only if the individual's MAGI
income is less than or equal to 300% of the FPL.
6. For MassHealth members enrolled in
MassHealth Standard, MassHealth CarePlus, CommonHealth, and Family Assistance,
excluding MassHealth Family Assistance -Children, the Health Safety Net pays
only for Adult Dental Services provided by a Community Health Center, Hospital
Licensed Health Center, or other Satellite Clinic that are not covered by
MassHealth.
7. For MassHealth
members, the Health Safety Net does not pay for, and Providers may not submit,
claims to the Office for MassHealth copayments.
8. For Low Income Patients enrolled in
Medicare (including Medicare Advantage), including MassHealth members eligible
for Medicare Buy-In and Senior Buy-In, the Health Safety Net pays for
Reimbursable Health Services not covered by the patient's insurance, and for
copayments, coinsurance, and deductibles required by the patient's
insurance.
9. The Health Safety Net
does not pay copayments for the Premium Assistance Payment Program Operated by
the Health Connector.
10. The
Health Safety Net pays for Reimbursable Health Services provided to Low Income
Patients for services provided during the Eligibility Period specified in
101 CMR
613.04(7).
(d)
Eligible Services
Limitations - Serious Reportable Events. The Health Safety Net
does not pay for services directly related to a Serious Reportable Event (SRE)
as defined in
105
CMR 130.332(A):
Definitions Applicable to
105
CMR 130.332
.
1. A Provider must not charge, bill, or
otherwise seek payment from the Health Safety Net, a Patient, or any other
payer as required by
105
CMR 130.332: Serious Reportable
Events (SREs) and Serious Adverse Drug Events (SADE), for services
provided as a result of an SRE occurring on premises covered by a Provider's
license, if the Provider determines that the SRE was
a. preventable;
b. within the Provider's control;
and
c. unambiguously the result of
a system failure as required by
105
CMR 130.332(B):
Reporting of SREs and (C): Preventability
Determination.
2. A Provider must not charge, bill, or
otherwise seek payment from the Health Safety Net, a Patient, or any other
payer as required by
105
CMR 130.332: Serious Reportable
Events (SREs) and Serious Adverse Drug Events (SADE) for services
directly related to
a. the occurrence of the
SRE;
b. the correction or
remediation of the event; or
c.
subsequent complications arising from the event as determined by the Health
Safety Net Office on a case-by-case basis.
3. A Provider may submit a claim for services
it provides that result from an SRE that did not occur on its premises only if
the treating facility and the facility responsible for the SRE do not have
common ownership or a common corporate parent.
4. Readmissions to the same hospital or
follow-up care provided by the same Provider or a Provider owned by the same
parent organization are not billable if the services are associated with the
SRE as described in 101 CMR 613.03(1)(d)2.
(2) Reimbursable Health Services.
(a)
General. The Health Safety Net pays only for the
Reimbursable Health Services listed below. Providers may submit claims only for
Reimbursable Health Services provided by Acute Hospitals and Community Health
Centers in accordance with the MassHealth Standard program using the payment
codes as listed in Subchapter 6 of the MassHealth Inpatient and
Outpatient Provider Manuals and other MassHealth Provider manuals,
unless otherwise specified in
101 CMR 614.00:
Health Safety Net Payments and Funding. The Health Safety Net
Office may add additional codes and Reimbursable Health Services by
administrative bulletin, as described in
101 CMR
613.08(4).
(b)
Pharmacy.
1. The Health Safety Net pays only for
prescribed drugs according to the coverage rules, including
130 CMR
406.411: Prescription
Requirements;
130 CMR
406.412(A): Drugs
and (B)(1);
130 CMR
406.413: Limitations on the Coverage
of Drugs; and
130 CMR
406.422: Prior
Authorization, established by MassHealth and processed through POPS.
Providers may not submit claims for drugs excluded from the MassHealth Drug
List.
2. Notwithstanding 101 CMR
613.03(2)(b)1., the Health Safety Net may pay for prescribed drugs designated
by the MassHealth agency as excluded from coverage for MassHealth members
through the 340B Drug Pricing Program pursuant to
130 CMR
406.404(D)(1):
Notification of Participation.
(c)
340B Pharmacies.
1. A 340B Provider may submit a Health Safety
Net claim only for outpatient pharmacy services provided through the Provider's
340B pharmacy unless the claim is submitted by a Provider that directly
operates both a 340B pharmacy and a retail pharmacy and the claim is for a drug
provided to an individual who cannot be seen by a Provider-based prescriber to
obtain a prescription within a clinically appropriate time period. The Provider
must inform the Patient that it may not fill future prescriptions unless the
individual becomes a Patient of the Provider or is placed on a waiting list in
the instance that the Provider is not accepting new patients. A Provider may
submit a Health Safety Net claim only for the dispensing fee for covered
prescribed drugs provided to Low Income Patients if that individual is using a
pharmaceutical company sponsored free drug program and the drug is dispensed by
the pharmacy. A Provider may not submit a Health Safety Net claim for free or
donated prescribed drugs where the drugs are stored and dispensed from a site
other than the pharmacy (e.g., secured closet near exam
room).
2. A 340B Provider must
provide the Health Safety Net Office 90 days' advance written notice of its
intent to discontinue providing prescribed drugs to Low Income Patients or
submitting claims to the Health Safety Net for outpatient pharmacy services
pursuant to 101 CMR 613.03(2)(c)1.
(d)
Utilization
Review. The Health Safety Net Office conducts a utilization review
program designed to monitor the appropriateness of services for which payments
are made and to promote the delivery of care in the most appropriate
setting.
(e)
Noncovered
Services. The Health Safety Net does not pay for any of the
following services: nonmedical services, such as social, educational, and
vocational services; cosmetic surgery; canceled or missed appointments;
telephone conversations or consultations; court testimony; research or the
provision of experimental, cosmetic, unproven, or otherwise medically
unnecessary procedures or treatments; the provision of whole blood except for
the administrative and processing costs associated with the provision of blood
and its derivatives; the treatment of male or female infertility (including,
but not limited to, laboratory tests, drugs, and procedures associated with
such treatment; however, the Health Safety Net pays for the diagnosis of male
and female infertility); vocational rehabilitation services; sheltered
workshops; recreational services; life-enrichment services; alcohol or drug
drop-in centers; drugs used for the treatment of obesity; cough and cold
preparations; drugs related to the treatment of male or female infertility;
absorptive lenses of greater than 25% absorption; photochromatic lenses,
sunglasses, or fashion tints; treatment of congenital dyslexia; extended-wear
contact lenses; invisible bifocals; and the Welsh 4-Drop Lens.
(3) Reimbursable Health Services - Acute Hospitals.
(a) The Health Safety Net pays Acute
Hospitals only for the Reimbursable Health Services listed in 101 CMR
613.03(3)(a)1. through 34.
1.
Abortion Services. The Health Safety Net pays for
abortion services performed in accordance with the applicable provisions of
130 CMR
410.434: Abortion Services:
Reimbursable Services.
2.
Administrative Days. The Health Safety Net pays for
Administrative Days meeting the requirements set forth in
130 CMR
415.415: Reimbursable Administrative
Days and
130 CMR
415.416: Nonreimbursable
Administrative Days.
3.
Ambulatory Surgery Services.
4.
Audiologist
Services.
5.
Chiropractic Services.
6.
Dental Services.
The Health Safety Net pays only for dental services identified in Subchapter 6
of the MassHealth Dental Manual and for Adult Dental Services
not covered by MassHealth. Certain dental services may be subject to prior
authorization, as specified by the Health Safety Net Office in billing
instructions, administrative bulletins, or other written issuances.
7.
Durable Medical
Equipment. The Health Safety Net pays only for crutches and canes
provided during a Hospital Visit.
8.
Family Planning
Services.
9.
Hearing Instrument Services.
10.
Inpatient Hospice
Services.
11.
Inpatient Services.
12.
Inpatient
Psychiatric. The Health Safety Net pays only for services provided
in a Medicare certified psychiatric unit.
13.
Laboratory
Services. The Health Safety Net does not pay separately for
routine specimen collection and preparation for the purpose of clinical
laboratory analysis. Specimen collection and preparation is considered part of
the laboratory service.
14.
Medical Supplies. The Health Safety Net pays for
medical supplies used in the delivery of inpatient and outpatient care. It also
pays for spacers used with metered dose inhalers, nebulizers, diabetic
supplies, home glucose monitors, and portable peak flow monitors.
15.
Mental Health
Services. The Health Safety Net pays for mental health services
except for noncovered services in 101 CMR 613.03(2)(e). The Health Safety Net
pays only for mental health services that meet the requirements in the
MassHealth Acute Outpatient Hospital Manual at
130 CMR
410.471: Mental Health Services:
Introduction through
130 CMR
410.475: Mental Health Services:
Staffing Requirements, and
130 CMR
410.479(A):
Provision of Services.
16.
Nurse Midwife
Services.
17.
Nurse Practitioner Services.
18.
Observation
Services. Outpatient hospital services provided anywhere in an
Acute Hospital, to evaluate a Patient's medical condition and determine the
need for an inpatient admission. Observation services are provided under order
of a physician, consist of the use of a bed and intermittent monitoring by
professional licensed clinical staff, and may be provided for more than 24
hours.
19.
Orthotic
Services.
20.
Outpatient Services. Outpatient services are services
provided by Acute Hospital outpatient departments and by Hospital Licensed
Health Centers or other Satellite Clinics. Such services include, but are not
limited to, Emergency Services, Primary or Elective Care, observation services,
Ancillary Services, and day-surgery services.
21.
Outpatient Psychiatric
Services.
22.
Pharmacy Services.
23.
Physician
Services. The Health Safety Net pays only for services provided at
Acute Hospital sites by Acute Hospital-based physicians who are employed or
contracted by the Acute Hospital and who receive payment from the Acute
Hospital for their services.
24.
Podiatrist Services.
25.
Prosthetic
Services.
26.
Radiology Services.
27.
Rehabilitation
Services. For inpatient rehabilitation, the Health Safety Net pays
only for services provided in a Medicare certified rehabilitation
unit.
28.
Renal
Dialysis Services.
29.
Speech and Hearing Services.
30.
Sterilization
Services.
31.
Substance Use Disorder Services, including methadone
treatment as described in
130 CMR 418.000:
Substance Use Disorder Treatment Services, except for
noncovered services in 101 CMR 613.03(2)(e).
32.
Therapy
Services. The Health Safety Net pays only for therapy services as
defined in the MassHealth Acute Outpatient Hospital Manual, at
130 CMR 410.451(A) and
(B). Before therapy is initiated, there must
be a comprehensive evaluation of the Patient's medical condition, disability,
and level of functioning to determine the need for treatment and, when
treatment is indicated, to develop a treatment plan.
33.
Tobacco
Cessation. The Health Safety Net pays only for services as defined
by Subchapter 6 of the MassHealth Acute Hospital Outpatient
Manual.
34.
Vision Care Services. The Health Safety Net pays only
for services as defined in
130 CMR
410.481: Vision Care
Services.
(4) Reimbursable Health Services - Community Health Centers.
(a)
General. Community Health Centers may submit claims
only for Reimbursable Health Services set forth in 101 CMR 613.03(4)(b). The
Reimbursable Health Services must meet the requirements set forth in 101 CMR
613.03(4)(c).
1. Community Health Centers may
submit claims only for services provided under the Community Health Center's
clinic license.
2. A Community
Health Center may submit claims only for Reimbursable Health Services provided
on site, except for off-site 340B Pharmacy Services and certain Evaluation and
Management visits provided to the Community Health Center's Patients at an
Acute Hospital. A Community Health Center may submit claims for dentures
provided on site but manufactured or repaired at an off-site
contractor.
3. The Health Safety
Net does not pay Community Health Centers for performing, administering, or
dispensing experimental, cosmetic, unproven, or otherwise medically unnecessary
procedures or treatments or treatment of male or female infertility (including,
but not limited to, laboratory tests, drugs, and procedures associated with
such treatment); however, the Health Safety Net pays for the diagnosis of male
and female infertility.
(b)
Reimbursable Health
Services.
1.
Audiology Services. The Health Safety Net pays for
audiology services if the services were provided at the written request of a
physician, nurse practitioner, or physician assistant who has found some
indication of a hearing problem. Documentation of the request and of the
hearing problem must be kept in the Patient's medical record. 2.
Behavioral Health Services.
3.
Cardiovascular and Pulmonary
Diagnostic Services.
4.
Dental Services.
The Health Safety Net pays for dental services identified in Subchapter 6 of
the MassHealth Dental Manual and for Adult Dental Services not
covered by MassHealth. Certain dental services may be subject to prior
authorization, as specified by the Health Safety Net Office in billing
instructions, administrative bulletins, or other written issuances.
5.
Diabetes Self-management
Training. The Health Safety Net pays for diabetes self-management
training services as defined by Subchapter 6 of the MassHealth
Community Health Center Manual.
6.
Electrocardiogram (EKG)
Services. The Health Safety Net pays for EKG services only when
the service is provided at the written request of a Community Health Center
staff physician who will interpret or review the interpretation of the EKG.
Documentation of the physician's request must be kept in the Patient's medical
record. A Community Health Center may claim payment for EKG services only when
the Community Health Center owns or rents its own EKG equipment and the EKG is
taken at the Community Health Center.
7.
Family Planning
Services. The Health Safety Net pays for family planning
counseling, prescribed drugs, family planning supplies, and laboratory
tests.
8.
Individual
Medical Visits. The Health Safety Net pays for face-to-face
meetings at a Community Health Center between a Patient and a physician,
physician assistant, nurse practitioner, nurse midwife, registered nurse, or
paraprofessional for medical examination, diagnosis, or treatment.
9.
Laboratory
Services. The Health Safety Net pays only for laboratory services
for which a written request for that service from an authorized subscriber is
present in the Patient's medical record. The Office does not pay for the
following laboratory services: routine specimen collection and preparation for
the purpose of clinical laboratory analysis (for example, venipunctures, urine,
fecal, and sputum samples; Pap smears; cultures; and swabbing and scraping for
removal of tissue); laboratory tests associated with treatment of male or
female infertility (however, the Health Safety Net pays for the diagnosis of
male and female infertility); or such calculations as red cell indices, A/G
ratio, creatinine clearance, and those ratios calculated as part of a profile.
The Office does not pay a Community Health Center for a laboratory service when
the Community Health Center bills separately for the professional component of
that service.
10.
Medical Nutrition Therapy. The Health Safety Net pays
for medical nutrition therapy services as defined by Subchapter 6 of the
MassHealth Community Health Center Manual. Medical nutrition
therapy does not include enteral therapy.
11.
Obstetrical
Services.
12.
Pharmacy Services.
13.
Podiatry
Services.
14.
Radiology Services. The Health Safety Net pays for
radiology services only when the services are provided at the written request
of a licensed physician or dentist. The professional component of a radiology
service is the component for interpreting a diagnostic test or image. The
technical component of a radiology service is the component for the cost of
rent, equipment, utilities, supplies, administrative and technical supplies and
benefits, and other overhead expenses.
15.
Surgery
Services.
16.
Tobacco Cessation Services. The Health Safety Net pays
for tobacco cessation services as defined by Subchapter 6 of the
MassHealth Community Health Center Manual.
17.
Vision Care
Services.
18.
Immunization Visits and Vaccines.
(c)
Reimbursable Health Services
Requirements. The Health Safety Net pays only for services
provided by the licensed professionals listed in the HSN CHC Billable Procedure
Codes list and pays in accordance with
101 CMR 614.00:
Health Safety Net Payments and Funding.
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