Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 410.000 - Outpatient hospital services
Section 410.451 - Therapist Services

Universal Citation: 130 MA Code of Regs 130.410

Current through Register 1531, September 27, 2024

(A) The MassHealth agency pays for occupational, physical, and speech/language therapy provided in hospital outpatient departments by or under the supervision of licensed therapists. Therapist services include the following:

(1) individual treatment;

(2) comprehensive evaluation;

(3) group therapy; and

(4) design and fitting of an adaptive device.

(B) All therapy must be provided subsequent to a written referral from a licensed physician or licensed nurse practitioner. The MassHealth agency pays for continuing physical, occupational, or speech/language therapy only when the referral is renewed in writing every 60 days, subject to the prior-authorization requirements described in 130 CMR 410.408(E).

(C) Before therapy is initiated, a comprehensive evaluation of the member's medical condition, disability, and level of functioning must be performed to determine the need for treatment and, when treatment is indicated, to develop a treatment plan. A comprehensive evaluation must include preparation of a written report for the member's medical record that contains at least the following information:

(1) the member's name and address;

(2) the name of the referring physician or nurse practitioner;

(3) objective evaluation findings;

(4) a detailed treatment plan prescribing the type, amount, estimated frequency, and duration of therapy and indicating the diagnosis and anticipated goals, or the reason treatment is not indicated;

(5) a description of any conferences with the member, the member's family or clinician, or other interested persons;

(6) other health care evaluations, as indicated;

(7) a description of the member's psychosocial and health status that includes:
(a) the present effects of the disability on both member and family;

(b) a brief history, the date of onset, and any past treatment of the disability;

(c) the member's level of functioning, both current and before onset of the disability, if applicable; and

(d) any other significant physical or mental disability that may affect therapy;

(8) for speech/language therapy only:
(a) assessments of articulation, stimulability, voice, fluency, and receptive and expressive language;

(b) a description of the member's cognitive functioning; and

(c) a description of the member's communication needs and motivation for treatment;

(9) for physical or occupational therapy only: a description of the member's physical limitations; and

(10) the therapist's signature and the date of the evaluation.

(D) The hospital must obtain prior authorization as a prerequisite to payment for certain outpatient therapy services pursuant to 130 CMR 410.408(E).

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