Level-of-Care Criteria for Members in Chronic Disease and Massachusetts Department of Public

Health Hospitals (A) Introduction. Services in chronic disease and Massachusetts Department of Public Health hospitals are reimbursable only when the member meets the level-of-care criteria in 130 CMR 435.409(B)(1) or (2). (B) Level-of-Care Criteria. In determining medical necessity, the Division or its agent applies the criteria in 130 CMR 409(B)(1) and (2). In addition, the Medicare Adult Appropriateness Evaluation Protocol (AEP) utilized by the Peer Review Organization (PRO) is used as a guide. To be medically necessary, an admission to or continued stay in a chronic disease or Massachusetts Department of Public Health hospital must meet one of the following two criteria, in compliance with 130 CMR 450.204. (1) The member must require services that: (a) can be provided safely and effectively at a chronic disease hospital level. Such services must be ordered by a physician and documented in the member's record; and (b) include at least daily physician intervention or the 24-hour availability of medical services and equipment available only in a hospital setting. (2) The member's medical condition and treatment needs are such that no effective, less costly alternative placement is available to the member.