Outpatient Hospital Services: Payment Limitations

(A) Time Limit. Payment for outpatient hospital visits is limited to one outpatient hospital visit per day per member per physician. (B) Visit and Treatment/Procedure. (1) The physician may bill for either a hospital outpatient visit, or for a treatment/procedure during a hospital outpatient visit, but may not bill for both a visit and a treatment/procedure for the same member on the same date at the same hospital. This limitation does not apply to a significant, separately identifiable outpatient hospital visit provided by the same physician on the same day as the procedure or other service. (2) The MassHealth agency pays either a physician or an outpatient hospital, but not both, for physician services provided in an outpatient hospital setting. The MassHealth agency does not separately pay a hospital for other professional services provided in an outpatient hospital setting. (3) An outpatient hospital setting includes a hospital’s outpatient department, emergency department, HLHC, and any other satellite of the hospital. A hospital outpatient visit includes a visit to any outpatient hospital setting.