(A)
Clinical Eligibility for Continuous Skilled Nursing
Services. A member is clinically eligible for MassHealth coverage
of CSN services when all of the following criteria are met:
(1) there is a clearly identifiable, specific
medical need for a nursing visit to provide nursing services, as described in
130
CMR 414.408(B), of more than
two continuous hours;
(2) the CSN
services are medically necessary to treat an illness or injury in accordance
with 130 CMR
414.409(C); and
(3) the nurse has obtained prior
authorization in accordance with
130
CMR 414.413.
(B)
Clinical Criteria for Nursing
Services.
(1) A nursing service
is a service that must be provided by an RN or LPN to be safe and effective,
considering the inherent complexity of the service, the condition of the
patient, and accepted standards of medical and nursing practice.
(2) Some services are nursing services on the
basis of complexity alone (for example, intravenous and intramuscular
injections). However, in some cases, a service that is ordinarily considered
unskilled may be considered a nursing service because of the patient's
condition. This situation occurs when only an RN or LPN can safely and
effectively provide the service.
(3) When a service can be safely and
effectively performed (or self-administered) by the average nonmedical person
without the direct intervention of an RN or LPN, the service is not considered
a nursing service, unless there is no one trained and able to provide
it.
(4) The independent nurse must
assess the member to ensure that continued nursing services are necessary.
Medical necessity of services is based on the condition of the patient at the
time the services were ordered and what was, at that time, expected to be
appropriate treatment throughout the certification period.
(5) A member's need for nursing care is based
solely on their unique condition and individual needs, whether the illness or
injury is acute, chronic, terminal, stable, or expected to extend over a long
period.
(C)
Member Must Be under the Care of a Physician or Ordering
Non-physician Practitioner. The MassHealth agency pays for CSN
services only if the member's physician or ordering non-physician practitioner
certifies the medical necessity for such services on an established individual
plan of care in accordance with
130
CMR 414.412. A member may receive CSN
services only if the member is under the care of a physician or ordering
non-physician practitioner.
(D)
Safe Maintenance in the Community. The member's
physician or ordering non-physician practitioner and the independent nurse must
determine that the member can be maintained safely in the community with
medically appropriate CSN services.
