Therapist Services: Covered Services

(A) The MassHealth agency pays for occupational, physical, and speech/language therapy provided in hospital outpatient departments by or under the supervision of licensed therapists. Therapist services include the following: (1) individual treatment; (2) comprehensive evaluation; (3) group therapy; and (4) design and fitting of an adaptive device. (B) All therapy must be provided subsequent to a written referral from a licensed physician or licensed nurse practitioner. The MassHealth agency pays for continuing physical, occupational, or speech/language therapy only when the referral is renewed in writing every 60 days, subject to the prior authorization requirements described in 130 CMR 410.408(E). (C) Before therapy is initiated, a comprehensive evaluation of the member's medical condition, disability, and level of functioning must be performed to determine the need for treatment and, when treatment is indicated, to develop a treatment plan. A comprehensive evaluation must include preparation of a written report for the member's medical record that contains at least the following information: (1) the member's name and address; (2) the name of the referring physician or nurse practitioner; (3) objective evaluation findings; (4) a detailed treatment plan prescribing the type, amount, estimated frequency, and duration of therapy and indicating the diagnosis and anticipated goals, or the reason treatment is not indicated; (5) a description of any conferences with the member, the member's family or clinician, or other interested persons; (6) other health care evaluations, as indicated; (7) a description of the member's psychosocial and health status that includes (a) the present effects of the disability on both member and family; (b) a brief history, the date of onset, and any past treatment of the disability; (c) the member's level of functioning, both current and before onset of the disability, if applicable; and (d) any other significant physical or mental disability that may affect therapy; (8) for speech/language therapy only: (a) assessments of articulation, stimulability, voice, fluency, and receptive and expressive language; (b) a description of the member's cognitive functioning; and (c) a description of the member's communication needs and motivation for treatment; (9) for physical or occupational therapy only: a description of the member’s physical limitations; and (10) the therapist's signature and the date of the evaluation. (D) The hospital must obtain prior authorization as a prerequisite to payment for certain outpatient therapy services pursuant to 130 CMR 410.408(E). 4. Program Regulations