Service Limitations

(A) The MassHealth agency pays a therapist for no more than one individual treatment and one group therapy session per member per day. For further description of payable service codes and modifiers, see Subchapter 6 - Service Codes and Descriptions of the Therapist Services Manual. (B) The MassHealth agency does not pay for a treatment claimed for the same date of service as an evaluation or reevaluation, since the evaluation or reevaluation fee includes payment both for a written report and for any treatment provided at the time of the evaluation or reevaluation. (C) The MassHealth agency pays a therapist for providing services in a Medicare-certified long- term-care facility subject to 130 CMR 432.413(A) and only in the following circumstances: (1) the member is not covered for therapy services under Medicare Part A or B; or (2) (a) the member is covered for therapy services under Medicare, but the facility or the therapist has submitted the claim to Medicare, and Medicare has denied payment; and (b) the therapist has obtained prior authorization as necessary in accordance with 130 CMR 432.417. (D) The MassHealth agency pays for the establishment of a maintenance program and the training of the member, member’s family, or other persons to carry it out, as part of a regular treatment visit, not as a separate service. (1) The MassHealth agency does not pay for performance of a maintenance program, except as provided in 130 CMR 432.414(D)(2). (2) In certain instances, the specialized knowledge and judgment of a licensed therapist may be required to perform services that are part of a maintenance program, to ensure safety or effectiveness that may otherwise be compromised due to the member’s medical condition. At the time the decision is made that the services must be performed by a licensed therapist, all information that supports the medical necessity for performance of such services by a licensed therapist, rather than a non-therapist, must be documented in the medical record.