Mental Health Services: Service Limitations

(A) Provision of Services. The MassHealth agency will pay for diagnostic and treatment services only when a professional staff member personally provides these services to the member or the member's family, or personally consults with a professional outside of the hospital outpatient department. The services must be provided to the member on an individual basis. (B) Multiple Sessions on the Same Date of Service. The MassHealth agency does not pay for more than one session of a single type of service provided to an individual member on the same day, except for the provision of psychotherapy for crisis. The MassHealth agency will pay for multiple different treatment modalities (i.e., individual therapy, family/couples therapy, group therapy, or psychotherapy for crisis) for the same member on the same day, but will not pay for a diagnostic service and a treatment modality for the same member on the same day. The MassHealth agency also will pay for case consultation and family consultation services regardless of whether a diagnostic service or one of the treatment modalities listed above is provided on the same day. (C) Case Consultation. (1) The MassHealth agency pays only for a case consultation that involves a personal meeting with a professional of another agency. (2) The MassHealth agency will pay for case consultation only when telephone contact, written communication, and other nonreimbursable forms of communication clearly will not suffice. Such circumstances must be documented in the member’s record. Such circumstances are limited to situations in which both the hospital outpatient department and the other party are actively involved in treatment or management programs with the member (or family members) and where a lack of face-to-face communication would impede a coordinated treatment program. (3) The MassHealth agency will not pay for court testimony. (D) 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 will not pay for group therapy when it is performed as an integral part of a psychiatric day treatment program. (E) Psychological Testing. The MassHealth agency will pay for psychological testing only when all of the following conditions are met. (1) The MassHealth agency pays for psychological testing when a qualified individual responsible for providing services to the member orders the testing. This ensures that the service is provided within the context of an overall service plan. A qualified individual includes a physician, psychologist, physician assistant, nurse practitioner, clinical nurse specialist, psychiatric clinical nurse specialist, or licensed independent clinical social worker who is either practicing independently, or as staff of a community health center, mental health center or hospital. Any other individual or entity wishing to request psychological testing services must coordinate with a qualified individual to obtain the necessary order. The MassHealth agency may deny or recover payment if the provider fails to provide to the MassHealth agency when requested, documented evidence that psychological testing was initiated and provided in accordance with 130 CMR 410.479(E). (2) Testing is performed by a psychologist who is licensed by the Massachusetts Board of Registration of Psychologists with a specialization listed in clinical or counseling psychology or a closely related specialty either personally administers the testing or personally supervises such testing during its administration by an unlicensed psychologist. (3) The psychologist must determine the specific tests to administer, and these tests must be 4. Program Regulations published, valid, and in general use, as defined by listing in the current edition of the Mental Measurement Yearbook or by their conformity to the Standards for Educational and Psychological Tests of the American Psychological Association; (4) Limitations on Psychological Testing. (a) The MassHealth agency does not pay for psychological testing provided as an outpatient hospital service if a psychologist has provided that test to the member within the preceding six months unless the following conditions exist and are documented in the billing provider’s medical record: 1. psychological testing is provided in order to ascertain changes relating to suicidal, homicidal, toxic, traumatic, or neurological conditions of the member; or 2. psychological testing is provided in order to ascertain changes following such special forms of treatment or interventions as electroconvulsive therapy (ECT) or psychiatric hospitalization. (b) The MassHealth agency does not pay for 1. periodic testing to measure the member’s response to psychotherapy; 2. self-rating forms and other paper-and-pencil instruments, unless administered as part of a comprehensive battery of tests and interpreted by the psychologist; 3. group forms of intelligence tests; or 4. an intelligence test performed at the same time as a brain assessment. (F) Family/Couple Therapy. Payment for family/couple therapy is limited to one fee per session, regardless of the number of staff members or family members present. (G) Home Visits. (1) The MassHealth agency will pay for intermittent home visits. Payment will also be made for home visits made for diagnostic purposes. (2) Home visits are reimbursable on the same basis as comparable services provided at the hospital outpatient department. Travel time to and from the member's home is not reimbursable. (3) A report of the home visit must be entered into the member's record. (H) Multiple Therapies. The MassHealth agency will pay for more than one mode of therapy used for a member during one week only if clinically justified; that is, when any single approach has been shown to be necessary but insufficient. The need for additional modes of treatment should be documented in the member's record. (I) Outreach Services Provided in Nursing Facilities. The MassHealth agency will pay for diagnostic and treatment services provided in a nursing facility to a member who resides in that nursing facility only in the following circumstances: (1) the nursing facility specifically requests treatment and the member's record at the nursing facility documents this request; (2) the treatment provided does not duplicate services usually provided in the nursing facility; (3) such services are generally available through the hospital outpatient department to members not residing in that nursing facility; and (4) the member either cannot leave the nursing facility or is sufficiently mentally or physically incapacitated to be unable to come to the hospital outpatient department alone. 4. Program Regulations