Payment

(A) Payment for psychiatric hospital outpatient services in Massachusetts will be made at the rate for services established in the signed provider contract with the MassHealth agency, subject to the limitations set forth in 130 CMR 434.407. (B) For purposes of making payments, the following limitations apply. (1) The MassHealth agency will not pay for psychiatric hospital outpatient services provided to a member who is an inpatient at the same or a different hospital on the same day. (2) If a member receives psychiatric hospital outpatient services at one facility and, later on the same day, is admitted as an inpatient to another facility, the MassHealth agency will pay both hospitals for services. (3) When a member is admitted to inpatient status through the emergency room or outpatient department, the MassHealth agency will pay for only the inpatient stay. The MassHealth agency will not pay for services furnished in the emergency room or outpatient department on the admitting day. (C) Payment for out-of-state psychiatric hospital outpatient services will be made in accordance with the MassHealth (or equivalent) fee schedule of that state. (D) Payment for out-of-state psychiatric hospital outpatient services provided to an eligible Massachusetts member may be made only in the following instances: (1) emergency psychiatric hospital outpatient services are provided to a member; (2) psychiatric hospital outpatient services are provided to a member who lives in a community near the border of Connecticut, Maine, New Hampshire, New York, Rhode Island, or Vermont and for whom the out-of-state hospital is nearer than one in Massachusetts providing equivalent medical services; (3) prior authorization has been obtained from the MassHealth agency for nonemergency outpatient services provided to a member by the out-of-state psychiatric inpatient hospital that is more than 50 miles from the Massachusetts border.