Current through Register 1531, September 27, 2024
(A)
Provision of
Services.
(1) The MassHealth
agency will pay for diagnostic and treatment services only when a professional
staff member personally provides these services to the member or the member's
family, or personally consults with a professional outside of the hospital
outpatient department. The services must be provided to the member on an
individual basis.
(2) The
MassHealth agency will pay for only one session of the types of services listed
in 130 CMR 410.479(C) through (H) provided to an individual member on one date
of service. Return visits on the same date of service are not
reimbursable.
(B)
Multiple Sessions on the Same Date of Service. The
MassHealth agency does not pay for more than one session of a single type of
service provided to an individual member on the same day, except for the
provision of psychotherapy for crisis. The MassHealth agency will pay for
multiple different treatment modalities (i.e., individual
therapy, family/couples therapy, group therapy, or psychotherapy for crisis)
for the same member on the same day, but will not pay for a diagnostic service
and a treatment modality for the same member on the same day. The MassHealth
agency also will pay for case consultation and family consultation services
regardless of whether a diagnostic service or one of the treatment modalities
listed above is provided on the same day.
(C)
Case
Consultation.
(1) The MassHealth
agency pays only for a case consultation that involves a personal meeting with
a professional of another agency.
(2) MassHealth agency will pay for case
consultation only when telephone contact, written communication, and other
nonreimbursable forms of communication clearly will not suffice. Such
circumstances must be documented in the member's record. Such circumstances are
limited to situations in which both the hospital outpatient department and the
other party are actively involved in treatment or management programs with the
member (or family members) and where a lack of face-to-face communication would
impede a coordinated treatment program.
(3) The MassHealth agency will not pay for
court testimony.
(D)
Group Therapy.
(1)
Payment is limited to one fee per group member with a maximum of 12 members per
group regardless of the number of staff members present.
(2) The MassHealth agency will not pay for
group therapy when it is performed as an integral part of a psychiatric day
treatment program.
(E)
Psychological Testing. The MassHealth agency will pay
for psychological testing only when all of the following conditions are met.
(1) The MassHealth agency pays for
psychological testing when a qualified individual responsible for providing
services to the member orders the testing. This ensures that the service is
provided within the context of an overall service plan. A qualified individual
includes a physician, psychologist, physician assistant, nurse practitioner,
clinical nurse specialist, psychiatric clinical nurse specialist, or licensed
independent clinical social worker who is either practicing independently, or
as staff of a community health center, mental health center or hospital. Any
other individual or entity wishing to request psychological testing services
must coordinate with a qualified individual to obtain the necessary order. The
MassHealth agency may deny or recover payment if the provider fails to provide
to the MassHealth agency when requested, documented evidence that psychological
testing was initiated and provided in accordance with
130
CMR 410.479(E).
(2) Testing is performed by a psychologist
who is licensed by the Massachusetts Board of Registration of Psychologists
with a specialization listed in clinical or counseling psychology or a closely
related specialty who either personally administers the testing or personally
supervises such testing during its administration by an unlicensed
psychologist.
(3) The psychologist
must determine the specific tests to administer, and these tests must be
published, valid, and in general use, as defined by listing in the current
edition of the Mental Measurement Yearbook or by their
conformity to the Standards for Educational and Psychological Tests of the
American Psychological Association.
(4)
Limitations on Psychological
Testing.
(a) The MassHealth
agency does not pay for psychological testing provided as an outpatient
hospital service if a psychologist has provided that test to the member within
the preceding six months unless the following conditions exist and are
documented in the billing provider's medical record:
1. psychological testing is provided in order
to ascertain changes relating to suicidal, homicidal, toxic, traumatic, or
neurological conditions of the member; or
2. psychological testing is provided in order
to ascertain changes following such special forms of treatment or interventions
as electroconvulsive therapy (ECT) or psychiatric hospitalization.
(b) The MassHealth agency does not
pay for:
1. periodic testing to measure the
member's response to psychotherapy;
2. self-rating forms and other
paper-and-pencil instruments, unless administered as part of a comprehensive
battery of tests and interpreted by the psychologist;
3. group forms of intelligence tests;
or
4. an intelligence test
performed at the same time as a brain assessment.
(F)
Family/Couple Therapy. Payment for family/couple
therapy is limited to one fee per session, regardless of the number of staff
members or family members present.
(G)
Home Visits.
(1) The MassHealth agency will pay for
intermittent home visits. Payment will also be made for home visits made for
diagnostic purposes.
(2) Home
visits are reimbursable on the same basis as comparable services provided at
the hospital outpatient department. Travel time to and from the member's home
is not reimbursable.
(3) A report
of the home visit must be entered into the member's record.
(H)
Multiple
Therapies. The MassHealth agency will pay for more than one mode
of therapy used for a member during one week only if clinically justified; that
is, when any single approach has been shown to be necessary but insufficient.
The need for additional modes of treatment should be documented in the member's
record.
(I)
Outreach
Services Provided in Nursing Facilities. The MassHealth agency
will pay for diagnostic and treatment services provided in a nursing facility
to a member who resides in that nursing facility only in the following
circumstances:
(1) the nursing facility
specifically requests treatment and the member's record at the nursing facility
documents this request;
(2) the
treatment provided does not duplicate services usually provided in the nursing
facility;
(3) such services are
generally available through the hospital outpatient department to members not
residing in that nursing facility; and
(4) the member either cannot leave the
nursing facility or is sufficiently mentally or physically incapacitated to be
unable to come to the hospital outpatient department alone.
