Current through Register 1531, September 27, 2024
(A)
Requirements.
(1) The MassHealth agency conducts admission
screening on elective admissions only. The admitting provider must telephone or
fax the MassHealth agency at least seven calendar days before a proposed
elective admission and provide the information specified in the appendix
described in
130
CMR 450.207(B). When the
admitting provider cannot notify the MassHealth agency within seven calendar
days, the admitting provider must notify the MassHealth agency prior to the
elective admission, and no later than 5:00 P.M. on the first day after the
decision to admit. The provider must explain to the MassHealth agency why the
seven-calendar-day notice requirement was not met. If the MassHealth agency
cannot complete the admission-screening process before the scheduled elective
admission, when neither the admitting provider nor the acute inpatient hospital
has informed the MassHealth agency at least seven calendar days before the
admission was scheduled, the provider may be required to reschedule the
admission.
(2) Providers must
notify the MassHealth agency of any changes in an approved elective admission
as soon as those changes are known, but in any event, before the admission
occurs. The MassHealth agency will deny payment if a service or procedure that
is provided is not what was proposed and approved, and such procedure, service,
or admission is not medically necessary.
(3) For postponed admissions, the admitting
provider must contact the MassHealth agency and provide updated information no
later than 5:00 P.M. on the second business day following the originally
planned admission date.
(B)
Notice of Admission Screening
Decisions. The MassHealth agency sends written notice of its
decisions to the admitting provider, PCC (if applicable), acute inpatient
hospital, and member.
(C)
Appeal of Admission Screening Decisions.
(1) If the MassHealth agency determines that
an acute inpatient hospital admission is not medically necessary, the admitting
provider or the PCC may request a review of the determination. Such a request
must be made in writing and received by the MassHealth agency within seven
calendar days after the date of the determination notice. This written request
must include all documentation that the provider believes is pertinent for a
second review.
(2) Providers or
members may appeal the MassHealth agency's decision to deny an elective
admission by requesting a hearing before the MassHealth agency's Board of
Hearings. Provider hearings are governed by
130 CMR
450.241 through
450.248.
Member hearings are governed by the MassHealth agency's regulations at 130 CMR
610.000: MassHealth Fair Hearing Rules. Neither providers nor
members are required to exhaust any other appeal rights before requesting a
hearing on an admission screening decision; however, providers and members do
not have a right to judicial review of an admission screening decision if they
fail to exhaust their administrative remedies.
(D)
Requesting
Reconsideration. If the MassHealth agency denies payment for a
claim because the admitting provider did not comply with the requirements of
130 CMR 450.208(A), the admitting provider or hospital may request
reconsideration of the MassHealth agency's decision by contacting the
MassHealth agency in writing within 30 calendar days after the date of the
remittance advice on which the claim is denied. The MassHealth agency will
process the claim only if the admitting provider or acute inpatient hospital
demonstrates that
(1) the admission was exempt
for one of the reasons described in
130
CMR 450.207(B)(4);
(2) the admitting provider, despite
reasonable, good-faith efforts to identify all third-party payment sources, was
unaware that the patient was a MassHealth member; or
(3) the admitting provider complied with all
requirements of 130 CMR 450.208(A).
