(A) The
MassHealth agency does not pay a physician for services provided under any of
the following circumstances.
(1) The services
were provided by a physician who individually or through a group practice has
contractual arrangements with an acute, chronic, or rehabilitation hospital,
medical school, or other medical institution that involve a salary,
compensation in kind, teaching, research, or payment from any other source, if
such payment would result in dual compensation for professional, supervisory,
or administrative services related to member care.
(2) The services were provided by a physician
who is an attending, visiting, or supervising physician in an acute, chronic,
or rehabilitation hospital but who is not legally responsible for the
management of the member's case with respect to medical, surgery, anesthesia,
laboratory, or radiology services.
(3) The services were provided by a physician
who is a salaried intern, resident, fellow, or house officer. 130 CMR 433.404
does not apply to a salaried physician when the physician supplements his or
her income by providing services during off-duty hours on premises other than
those of the institution that pays the physician a salary, or through which the
physician rotates as part of his or her training.
(4) The services were provided in a state
institution by a state-employed physician or physician consultant.
(5) Under comparable circumstances, the
physician does not customarily bill private patients who do not have health
insurance.
(B) The
MassHealth agency does not pay a physician for performing, administering, or
dispensing any experimental, unproven, cosmetic, or otherwise medically
unnecessary procedure or treatment.
(C) The MassHealth agency does not pay a
physician for the treatment of male or female infertility (including, but not
limited to, laboratory tests, drugs, and procedures associated with such
treatment); however, MassHealth does pay a physician for the diagnosis of male
or female infertility.
(D) The
MassHealth agency does not pay a physician for otherwise payable service codes
when those codes are used to bill for circumstances that are not payable
pursuant to 130 CMR 433.404.
