(A) Acute hospital outpatient departments and
hospital-licensed health centers in Massachusetts are paid for services
provided to eligible members according to the rate for services established in
the signed MassHealth provider agreement, subject to the limitations set forth
in 130 CMR 410.406.
(B) For
purposes of making payments to acute hospital outpatient departments and
hospital-licensed health centers in Massachusetts, the following limitations
apply.
(1) The MassHealth agency does not pay
for outpatient services provided to a member who is an inpatient at the same or
a different hospital on the same day.
(2) The MassHealth agency pays only for
emergency outpatient services provided to a member on the day that the member
is discharged from the hospital, whether from the same or a different
facility.
(3) If a member receives
outpatient services at one facility and, later on the same day, is admitted as
an inpatient to another facility, the MassHealth agency pays both hospitals for
services.
(4) When a member is
admitted to inpatient status through the emergency department or outpatient
department, the hospital must bill for only the inpatient stay. The MassHealth
agency does not pay for services furnished in the emergency department or
outpatient department on the admitting day.
(C) Chronic disease and rehabilation hospital
outpatient departments in Massachusetts are paid for services provided to
eligible members according to the rate of payment established for each hospital
in the signed MassHealth provider agreement, subject to the limitations set
forth in 130 CMR 410.406(C)(1) and (2).
(1)
Charges.
(a) The
MassHealth agency pays only those charges contained in the charge book that the
hospital has currently filed with the Center for Health Information and
Analysis and no more than those charges.
(b) For changes in charges, the appropriate
EOHHS regulations apply.
(c) In
those cases where a specific rate has been established by EOHHS for a specific
service or program (such as for adult day health services), the MassHealth
agency pays no more than that rate.
(2)
Payments. For
purposes of making payments to chronic disease and rehabilation outpatient
hospitals, the following limitations apply.
(a) The MassHealth agency does not pay for
outpatient services provided to a member who is an inpatient at the same or a
different hospital on the same day.
(b) The MassHealth agency pays only for
emergency outpatient services provided to a member on the day that he or she is
discharged from the hospital, whether from the same or a different
facility.
(c) If a member receives
outpatient services at one facility and, later on the same day, is admitted as
an inpatient to another facility, the MassHealth agency pays both hospitals for
services.
(d) When a member is
admitted to inpatient status through the emergency department or outpatient
department, the hospital must bill for only the all-inclusive per
diem rate for that day. The MassHealth agency does not pay for
services furnished in the emergency department or outpatient department on the
admitting day.
(D) The MassHealth agency pays for laboratory
services in accordance with
130 CMR
410.456.
