Individual Consideration

MassHealth has designated certain services in Subchapter 6 of the Vision Care Manual as requiring individual consideration. This means that the MassHealth agency will establish the appropriate rate for these services based on the standards and criteria set forth in 130 CMR 402.407(B). Providers claiming payment for any service requiring individual consideration must submit with such claim a report that includes a detailed description of the service, and is accompanied by supporting documentation that may include, but is not limited to, a descriptive report, or in the case of a purchase, a copy of the supplier's invoice. The MassHealth agency does not pay claims for services requiring individual consideration unless it is satisfied that the report and documentation submitted by the provider are adequate to support the claim. (A) The MassHealth agency determines the appropriate payment for a service requiring individual consideration in accordance with the following standards and criteria: (1) the amount of time required to perform the service; (2) the degree of skill required to perform the service; (3) the severity and complexity of the member's disease, disorder, or disability; (4) any applicable relative-value studies; (5) any complications or other circumstances that the MassHealth agency deems relevant; (6) the policies, procedures, and practices of other third-party insurers; and (7) for ophthalmic materials or supplies, a copy of the invoice from the supplier showing the actual acquisition cost.