Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 434.000 - Psychiatric Hospital Outpatient Services
Section 434.430 - Mental Health Services: Service Limitations

Universal Citation: 130 MA Code of Regs 130.434

Current through Register 1531, September 27, 2024

(A) Length and Frequency of Sessions.

(1) The MassHealth agency pays 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 pays for only one session of the types of services listed in 130 CMR 434.430(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) Diagnostic Services. Payment for diagnostic services provided to a member is limited to a maximum of four hours or eight units.

(C) Individual Therapy. Payment for individual therapy is limited to a maximum of one hour per session per day.

(D) Family Therapy.

(1) Payment for family therapy is limited to a maximum of one-and-one-half hours per session per day.

(2) Payment also is limited to one payment per family therapy visit, regardless of the number of staff members or members who are present.

(E) Case Consultation.

(1) The MassHealth agency pays only for case consultation that lasts at least 30 minutes and involves a personal meeting with a professional of another agency. Payment is limited to a maximum of one hour persession.

(2) The MassHealth agency pays for case consultation only when telephone contact, written communication, and other non reimbursable forms of communication clearly will not suffice. Such circumstances must be documented in the member's record and also in the prior authorization request, if applicable. 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 does not pay for court testimony.

(F) Family Consultation. The MassHealth agency pays for a consultation with the natural or foster parent or legal guardian of a member less than 21 years of age who lives with the child, is responsible for the child's care, and is not an eligible member, when such consultation is integral to the treatment of the member.

(G) Group Therapy.

(1) The MassHealth agency pays only for a group therapy session that has a minimum duration of one hour and a maximum duration of two hours.

(2) Payment is limited to one fee per group member with a maximum of ten members per group regardless of the number of staff members present.

(3) The MassHealth agency does not pay for group therapy when it is performed as an integral part of a psychiatric day treatment program.

(H) Psychological Testing. The MassHealth agency pays for psychological testing only when the following conditions are met.

(1) 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 either personally administers the testing or personally supervises such testing during its administration by an unlicensed psychologist.

(2) A battery of tests is performed. These tests must meet the following standards:
(a) the tests are published, valid, and in general use, as evidenced by their presence 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;

(b) a personality evaluation contains the findings of at least two ofthe following test types or their age- appropriate equivalents: Rorschach, TAT (Thematic Apperception Test), TED (Tasks of Emotional Development), or MMPI (Minnesota Multiphasic Personality Inventory), and one or more of the following test types: figure drawing, Bender-Gestalt, or word association;

(c) intelligence testing includes either a full Wechsler or Stanford-Binet instrument or an equivalent; and

(d) assessment of brain damage contains at least the findings of a Wechsler Intelligence Scale and tests of recent memory, visual-space perception, and other functions commonly associated with brain damage.

(3) Except as explained below, the MassHealth agency does not pay for
(a) self-rating forms and other paper-and-pencil instruments, unless administered as part of a comprehensive battery of tests;

(b) group forms of intelligence tests;

(c) an intelligence test performed at the same time as a brain assessment;

(d) short-form, abbreviated, or "quick" intelligence tests administered at the same time as the Wechsler or Stanford-Binet tests; otherwise, such tests are reimbursable only at a lower rate than standard intelligence tests on an individual consideration basis; or

(e) a repetition of any psychological test or tests provided to the same member within the preceding six months, unless accompanied by documentation demonstrating that the purpose of the repeated testing is to ascertain changes following such special forms of treatment or intervention as electroshock therapy or psychiatric hospitalization (periodic testing to measure the member's response to psychotherapy is not reimbursable); or relating to suicidal, homicidal, toxic, traumatic, or neurological conditions. Submission of such documentation with the claim for payment is sufficient when the psychological test or tests are to be performed on the same member a second time within a six-month period. Further repetitions will be paid for by the MassHealth agency only if this documentation is submitted and prior authorization granted by the MassHealth agency prior to the testing (see 130 CMR 434.409) .

(4) Testing of a member requested by responsible parties, such as but not limited to physicians, clinics, hospitals, schools, courts, group homes, or state agencies, must be documented in the member's record. Such documentation must include the referral source and the reason for the referral.

(I) Medication Visits. The MassHealth agency does not pay for a medication visit as a separate service when it is performed as part of another treatment service (for example, a diagnostic assessment or individual or group therapy performed by a psychiatrist).

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