Payment

(A) Acute hospital outpatient departments and hospital-licensed health centers in Massachusetts are paid for services provided to eligible members according to the rate for services established in the signed MassHealth provider agreement, subject to the limitations set forth in 130 CMR 410.406. (B) For purposes of making payments to acute hospital outpatient departments and hospital-licensed health centers in Massachusetts, the following limitations apply. (1) The MassHealth agency does not pay for outpatient services provided to a member who is an inpatient at the same or a different hospital on the same day. (2) The MassHealth agency pays only for emergency outpatient services provided to a member on the day that the member is discharged from the hospital, whether from the same or a different facility. (3) If a member receives outpatient services at one facility and, later on the same day, is 4. Program Regulations admitted as an inpatient to another facility, the MassHealth agency pays both hospitals for services. (4) When a member is admitted to inpatient status through the emergency department or outpatient department, the hospital must bill for only the inpatient stay. The MassHealth agency does not pay for services furnished in the emergency department or outpatient department on the admitting day. (C) Chronic disease and rehabilitation hospital outpatient departments in Massachusetts are paid for services provided to eligible members according to the rate of payment established for each hospital in the signed MassHealth provider agreement, subject to the limitations set forth in 130 CMR 410.406(C)(1) and (2). (1) Charges. (a) The MassHealth agency pays only those charges contained in the charge book that the hospital has currently filed with the Center for Health Information and Analysis and no more than those charges. (b) For changes in charges, the appropriate EOHHS regulations apply. (c) In those cases where a specific rate has been established by EOHHS for a specific service or program (such as for adult day health services), the MassHealth agency pays no more than that rate. (2) Payments. For purposes of making payments to chronic disease and rehabilitation outpatient hospitals, the following limitations apply. (a) The MassHealth agency does not pay for outpatient services provided to a member who is an inpatient at the same or a different hospital on the same day. (b) The MassHealth agency pays only for emergency outpatient services provided to a member on the day that he or she is discharged from the hospital, whether from the same or a different facility. (c) If a member receives outpatient services at one facility and, later on the same day, is admitted as an inpatient to another facility, the MassHealth agency pays both hospitals for services. (d) When a member is admitted to inpatient status through the emergency department or outpatient department, the hospital must bill for only the all inclusive per diem rate for that day. The MassHealth agency does not pay for services furnished in the emergency department or outpatient department on the admitting day. (D) The MassHealth agency pays for laboratory services in accordance with 130 CMR 410.456.