Inpatient Hospital Services: Service Limitations and Screening Requirements

(A) Hospital inpatient visit fees apply to visits by physicians to members hospitalized in acute, chronic, or rehabilitation hospitals. Payment is limited to one visit per day per member for the length of the member's hospitalization. (B) The MassHealth agency does not routinely pay for visits to members who have undergone or who are expected to undergo surgery, since the allowable surgical fees include payment for the provision of routine inpatient preoperative and postoperative care. In unusual circumstances, however, the MassHealth agency does pay for such visits. (C) The MassHealth agency pays only the attending physician for inpatient hospital visits, with the following exceptions. (1) The MassHealth agency pays for consultations by a physician other than the attending physician. (See 130 CMR 433.418 for regulations about consultations.) (2) If it is necessary for a physician other than the attending physician to treat a hospitalized member, the other physician's services are payable. An explanation of the necessity of such 4. Program Regulations visits must be attached to the claim. The MassHealth agency will review the claim and determine appropriate payment to the other physician. (D) The MassHealth agency pays either a physician or an inpatient hospital, but not both, for physician services provided in an inpatient hospital setting. The MassHealth agency does not separately pay a hospital for other professional services provided in an inpatient hospital setting.