Definitions

The following terms used in 130 CMR 428.000 have the meanings given in 130 CMR 428.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 428.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 428.000 and 130 CMR 450.000: Administrative and Billing Regulations. Accessory Equipment. Equipment that is fabricated primarily and customarily to modify or enhance the usefulness or functional capability of another piece of prosthetic equipment and that is generally not useful in the absence of such prosthetic equipment. Adjusted Acquisition Cost. Except where the manufacturer is the provider, the price paid by the provider to the manufacturer or any other supplier for prosthetic devices, customized equipment, or supplies, excluding all associated costs such as shipping, handling, and insurance costs in accordance with 130 CMR 428.422. Where the manufacturer is the provider, the adjusted acquisition cost is the actual cost of manufacturing such prosthetic devices, customized equipment, or supplies. American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. (ABC). The national certifying and accrediting body for the orthotic, prosthetic, and pedorthic professions. Board of Certification/Accreditation, International (BOC). A credentialing entity for practitioners and suppliers of comprehensive orthotic and prosthetic care. Certified Mastectomy Fitter (CMF). A health care professional with current certification through the ABC or BOC who is specifically educated and trained in the provision of breast prostheses and post-mastectomy services, including patient assessment, formulation of a treatment plan, implementation of the treatment plan and follow-up, and practice management. Date of Service. The date the prosthesis is delivered and fitted to the MassHealth member. If the prosthetic service involves a series of fittings and adjustments, the date of service is the date on which the final adjustment is made. If the prosthetic service involves only the provision of a service (for example, a repair), then the date of service is the date on which the service was completed. Discount. Any remuneration or reduction of payment of any kind, whether direct or indirect, received by the provider. Nursing Facility. A licensed facility that meets the provider-eligibility and certification requirements of 130 CMR 456.404: Requirements for Provider Participation: In-state or 130 CMR 456.405: Requirements for Provider Participation: Out-of-state and whose members meet the medical eligibility criteria under 130 CMR 456.409: Services Requirement for Medical Eligibility. Nursing facilities do not include facilities such as rest homes, state schools, and state hospitals. Nursing Facility Visit. A visit by a provider to a nursing facility for the purpose of providing prosthetic services. Prior Authorization (PA) Request. A request submitted by the orthotics provider to the MassHealth agency to determine medical necessity in accordance with 130 CMR 442.412: Prior Authorization, 450.204: Medical Necessity, and 450.303: Prior Authorization. Prosthesis (or Prosthetic Equipment). An artificial replacement for a missing body part, such as an artificial limb or total joint replacement. Prosthetics Provider. An organization or individual that has enrolled with MassHealth and has signed a provider contract with the MassHealth agency who meets all applicable requirements of 130 CMR 428.404 and 450.000: Administrative and Billing Regulations. Prosthetics providers may include providers also enrolled as MassHealth participating durable medical equipment (DME) and supplies providers, oxygen and respiratory therapy equipment and supplies (OXY) providers, or orthotics services providers, who meet all program-specific requirements. Prosthetic Service. The purchase, customization, fitting, repair, replacement, or adjustment of a prosthesis or component part, or other activity performed or equipment provided in accordance with 130 CMR 428.000. Prosthetic Supplies. Products that are: (1) fabricated primarily and customarily to fulfill a medical purpose; (2) used in conjunction with a prosthesis or prosthetic equipment; (3) generally not useful in the absence of a prosthesis; and (4) non-reusable and disposable. Prosthetics. The design, fitting, and attachment of an artificial replacement of a missing body part. Service Facility. The place of business, physically accessible to MassHealth members, where prosthetic services, especially those involving fitting, adjustment, repair, and replacement of prostheses, are performed. A service facility does not include a MassHealth member’s place of residence.