Service Limitations

(A) Diagnostic and Treatment Services. The MassHealth agency pays for diagnostic and treatment services only when a professional staff member, as defined by 130 CMR 429.424, personally provides these services to the member or the member's family or personally consults with a professional outside of the center. The services must be provided to the member on an individual basis and are not reimbursable if they are an aspect of service delivery, as defined in 130 CMR 429.408(B). (B) Multiple Visits on the 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 except for the provision of crisis intervention. Services rendered by BHUC-designated providers and billed through the encounter bundled rate will be paid by the MassHealth agency pursuant to 101 CMR 306.00: Rates for Mental Health Services Provided in Community Health Centers and Mental Health Centers. The MassHealth agency pays only one encounter bundled rate for each member on one date of service. The MassHealth agency will pay for one encounter of psychological assessment, neuropsychological assessment, comprehensive community support services, recovery support navigator, recovery coach, and certified peer specialist on the same date of service as the encounter bundled rate. The MassHealth agency will pay for only one of the following on a single date of service: Structured Outpatient Addiction Program (SOAP), Enhanced Structured Outpatient Addiction Program (E-SOAP), Intensive Outpatient Program, or the encounter bundled rate. (C) 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. (D) 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 only when 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 center 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 a center for court testimony. (E) Family Consultation. The MassHealth agency pays for consultation with family or other responsible persons who are not eligible members when such consultation is integral to the treatment of the member. (F) 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 does not pay for group therapy when it is performed as an integral part of a psychiatric day treatment services. (3) The MassHealth agency does not pay for group therapy when it is performed as an integral part of intensive outpatient program services. (G) Psychological Assessment. The MassHealth agency pays a center for psychological assessment only when the following conditions are met. (1) A psychologist who meets the qualifications in 130 CMR 429.424(C) either personally administers the assessment or personally supervises such assessment during its administration by an unlicensed psychologist trainee. (2) A psychologist must determine the specific tests to administer. All tests must be published, valid, and in general use, as defined by listing the current edition of the Mental Measurements Yearbook or by conformity to the Standards for Educational and Psychological Tests of the American Psychological Association. (3) Except as explained below, the MassHealth agency does not pay for psychological assessment that includes only (a) periodic assessment to measure the member’s response to psychotherapy; (b) self-rating forms and other paper-and-pencil instruments, unless administered as part of a comprehensive battery of tests; (c) group forms of intelligence tests; or (d) a repetition of any psychological assessment or assessments provided by the mental health center or any independent psychologist to the same 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 to ascertain changes relating to suicidal, homicidal, toxic, traumatic, or neurological conditions of the member; or 2. psychological assessment is provided to ascertain changes following such special forms of treatment or interventions as electroconvulsive therapy (ECT) or psychiatric hospitalization. (4) A responsible party requests the assessment of a member. Responsible parties include, but are not limited to, physicians, clinics, hospitals, schools, courts, group homes, or state agencies, and must be documented in the member's record. Such documentation must include the referral source and the reason for the referral. (H) Crisis Intervention. The MassHealth agency pays for crisis intervention as defined in 130 CMR 429.402. (1) This service is limited to face-to-face contacts, which includes telehealth, with the member. (2) The need for crisis intervention must be fully documented in the member's record for each date of crisis intervention services. (3) This service is limited to one initial unit of service and up to three add-on units of service per date of service. (I) Outreach Services Provided in Nursing Facilities. (1) The MassHealth agency pays a center for diagnostic and treatment services provided to a member residing in a nursing facility under the following circumstances and conditions: (a) the nursing facility specifically requests treatment, and the member's record at the nursing facility documents this request; (b) the treatment provided does not duplicate services that should be provided in the nursing facility; and (c) such services are generally available through the center to members not residing in that nursing facility. (2) The following conditions must also be met: (a) the member's record at the center must contain all of the information listed in 130 CMR 429.436; (b) the member's record at the nursing facility must contain information pertaining to diagnostic and treatment services including, but not limited to, medication, treatment plan, progress notes on services, case review, and utilization review; and (c) the member must function at a sufficient level to benefit from treatment as established by a clinical evaluation and by accepted standards of practice.