Service Limitations

(A) Frequency of Psychological Assessment. The MassHealth agency does not pay for a psychological assessment if the psychologist or another MassHealth provider has provided the same type of psychological assessment (intelligence, neuropsychological, developmental, or personality) 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 assessment is provided in order to ascertain changes relating to suicidal, homicidal, traumatic, or neurological conditions of the member; or (2) psychological assessment is provided in order to ascertain changes following specialized treatment or interventions such as electroconvulsive therapy (ECT) or inpatient psychiatric treatment. (B) The MassHealth agency does not pay for the following types of psychological assessments: (1) periodic evaluation 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; or (3) group forms of intelligence assessments. (C) Psychological Assessment. The psychologist is eligible to receive payment for the psychological assessment when administered by a technician only if: (1) the technician is trained to perform the individual tests; (2) the psychologist selects the specific tests to be included in the assessment; (3) the technician performs the tests under the direct, personal, and continuous supervision of the psychologist who must assume professional responsibility for the tests performed; and (4) the psychologist personally interprets the tests and writes the evaluation report. (D) Diagnostic and Individual Treatment Services. The MassHealth agency pays for diagnostic and treatment services only when a psychologist, as defined by 130 CMR 411.000, personally provides these services to the member or the member's family. The services must be provided to the member on an individual basis. (E) Multiple Visits on a Same Date of Service. The MassHealth agency pays for only one visit of a single type of service (except for diagnostics) provided to an individual member on one date of service. Return visits on the same date of service are not reimbursable. (F) Multiple Therapies. The MassHealth agency pays for more than one mode of therapy used for a member during one week when it is clinically justified, and when any single approach has been shown to be necessary but insufficient. The need for multiple therapies must be documented in the member's record. (G) Case Consultation. (1) The MassHealth agency pays only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings. (2) The MassHealth agency pays for case consultation delivered in person or via telephonic or audio-visual methods only when written communication alone, and other non-reimbursable 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 provider and the other party are actively involved in treatment or management programs with the member (or family members) and where a lack of direct communication would impede a coordinated treatment program. (3) The MassHealth agency does not pay the provider for court testimony. (H) Family Consultation. The MassHealth agency pays for consultation with family or other responsible persons who is not an eligible member, when such consultation is integral to the treatment of the member. (I) Group Therapy. (1) Payment is limited to one fee per group member with a maximum of 12 members per group. (2) The MassHealth agency does not pay for group therapy when it is performed as an integral part of a psychiatric day treatment services, or intensive outpatient program services.