Visits: Service Limitations

The following restrictions and limitations apply to visits as defined in 130 CMR 405.402. (A) Individual Medical Visit. An individual medical visit, including family planning, may not be for an individual mental health service or for HIV pre- or post-test counseling visits. (B) Individual Mental Health Visit. An individual mental health visit conducted by a person other than a psychiatrist or an advanced practice registered nurse (APRN) with a graduate degree and advanced training in psychiatric care (a psychiatric clinical nurse specialist or a psychiatric mental health nurse practitioner) is not reimbursable. Other mental health services provided by qualified clinicians and properly billed are reimbursable, but not as Individual Mental Health Visits. (C) Group Clinic Visit. All instructional group sessions for members must be carried out by a physician, physician assistant, certified nurse practitioner, clinical nurse specialist, or registered nurse. A group visit conducted by other kinds of professionals (for example, social workers, counselors, or nutritionists) is not reimbursable as a group clinic visit. These limitations do not apply to group clinic visits for tobacco cessation. (D) HIV Pre- and Post-test Counseling Visits. The CHC may be reimbursed for a maximum of two HIV pre-test counseling and two HIV post-test counseling visits per member per test. A maximum of four pre-test counseling visits and four post-test counseling visits per calendar year per member are reimbursable. (E) Home Visit. A home visit must be used to deliver episodic care in the member's home when a health practitioner has determined that it is not advisable for the member to visit the CHC. The medical record must document the reasons for a home visit. A housebound member with chronic medical and nursing care needs must be referred to a Medicare-certified home health agency. (F) Treatments or Procedures. The CHC may bill for a visit, a treatment, or a procedure, but may not bill for more than one of these services provided to the same member on the same date when the services are performed in the same location. This limitation does not apply to tobacco cessation counseling services provided by a physician or other qualified staff member under the supervision of a physician on the same day as a visit. Examples of treatments or procedures are a vasectomy, colposcopy, or an amniocentesis. X-rays, laboratory tests, and certain diagnostic tests may be billed in addition to an office visit. (G) Immunization or Injection. (1) The CHC may bill for either an office visit or vaccine administration, but may not bill for both an office visit and vaccine administration for the same member on the same date when the office visit and the vaccine administration are performed in the same location. This limitation does not apply to a significant, separately identifiable office visit provided by the same physician on the same day as the vaccine was administered. (2) The MassHealth agency pays for the cost of the injectable material unless the Massachusetts Department of Public Health distributes the injectable material free of charge. (H) Urgent Care. The MassHealth agency pays an enhanced fee for urgent care when such care is provided at the CHC Monday through Friday from 5:00 P.M. to 6:59 A.M., and from Saturday at 7:00 A.M. through Monday at 6:59 A.M. (I) Individual Psychotherapy. The MassHealth agency pays for psychotherapeutic services provided to an individual member. (J) Family and Couple Therapy. The MassHealth agency pays for therapy provided simultaneously in the same session to more than one member of the same family or to a couple whose primary complaint is the disruption of their marriage, family, or relationship. Payment is limited to one fee per session, regardless of the number of family members present or the presence of a cotherapist. (K) Group Therapy. (1) Payment is limited to one fee per group member with a maximum of 12 members per group regardless of the number of staff members present. (2) The MassHealth agency does not pay for group therapy when it is performed as an integral part of a psychiatric day treatment program. (L) Multiple-family Group Therapy. (1) Payment is limited to one fee per group member with a maximum of 10 members per group regardless of the number of staff members present. (2) The MassHealth agency does not pay for multiple-family group psychotherapy when it is performed as an integral part of a psychiatric day treatment program. (M) Diagnostic Services. The MassHealth agency pays for the examination and determination of a patient's physical, psychological, social, economic, educational, and vocational assets and disabilities for the purpose of designing a treatment plan. This service includes an initial medication evaluation. (N) Psychological Testing. The MassHealth agency pays for psychological testing only when provided by a licensed psychologist who either personally administers the testing or personally supervises such testing during its administration by an unlicensed psychologist.