(A)
Introduction.
130 CMR 450.207 through
450.209
describes the Utilization Management Program for acute inpatient hospitals. The
purpose of this program is to ensure that certain medical services for which
the MassHealth agency pays are medically necessary and provided in the
appropriate setting. To this end, the MassHealth agency conducts reviews before
elective admissions (admission screening) and after discharge but before
payment (prepayment review). The MassHealth agency also conducts utilization
reviews of inpatient admissions and outpatient services on a postpayment basis
pursuant to
130 CMR
450.237. The term "admitting provider" as
used in 130 CMR 450.207 through
450.209
refers to the provider (for example, physician or dentist) who admits the
member to the facility and who assumes primary responsibility for the member's
care and the admitting provider's designee, where appropriate. The requirements
of the Utilization Management Program detailed in 130 CMR 450.207 through
450.209
apply to both in-state and out-of-state hospitals.
(B)
General
Provisions.
(1)
Appendix. The MassHealth agency has issued an appendix
to the provider manual for each facility and admitting provider affected by the
Utilization Management Program. This appendix contains a list of information
the admitting provider must provide for each review, and the name, address, and
telephone number of the MassHealth agency's agent for the Utilization
Management Program.
(2)
Stipulations. The Utilization Management Program does
not waive or replace any other MassHealth agency requirements, such as
prior-authorization or consent-form requirements.
(3)
Payment
Restrictions.
(a) The MassHealth
agency will pay the acute inpatient hospital for services subject to the
Utilization Management Program only if the admitting provider has complied with
the requirements in 130 CMR 450.207 through
450.209
and the service is medically or administratively necessary.
(b) Payments are subject to all general
conditions and restrictions of the MassHealth agency.
(c) A provider may not bill the member for
any medical care for which the MassHealth agency has denied payment due to the
provider's failure to comply with the requirements of the Utilization
Management Program.
(4)
Exceptions. Proposed admissions of the following
members, are exempt from the requirements of the Utilization Management
Program, regardless of admitting diagnosis:
(a) members whose hospitalization is
court-ordered;
(b) recipients of
the EAEDC Program; and
(c) members
for whom MassHealth is not the primary payer of the acute inpatient admission,
including but not limited to members covered by an MCO, Accountable Care
Partnership Plan, SCO, ICO, commercial insurance, or Medicare. However, if the
primary payer denies coverage before the member is admitted or if the member
has Medicare Part B only, the admission of the member is not exempt from the
requirements of the Utilization Management Program.
