Clinical Eligibility Criteria for CSN Agency Services

(A) Clinical Criteria for Nursing Services. (1) A nursing service is a service that must be provided by an RN or LPN to be safe and effective, considering the inherent complexity of the service, the condition of the patient, and accepted standards of medical and nursing practice. (2) Some services are nursing services on the basis of complexity alone (for example, intravenous and intramuscular injections). However, in some cases, a service that is ordinarily considered unskilled may be considered a nursing service because of the patient’s condition. This situation occurs when only an RN or LPN can safely and effectively provide the service. (3) When a service can be safely and effectively performed (or self-administered) by the average nonmedical person without the direct intervention of an RN or LPN, the service is not considered a nursing service, unless there is no one trained and able to provide it. (4) The CSN agency must assess the member to ensure that continued nursing services are necessary. (5) Medical necessity of services is based on the condition of the patient at the time the services were ordered and what was, at that time, expected to be appropriate treatment throughout the certification period. (6) A member’s need for nursing care is based solely on their unique condition and individual needs, whether the illness or injury is acute, chronic, terminal, stable, or expected to extend over a long period. (B) Clinical Eligibility for CSN Services. A member is clinically eligible for MassHealth coverage of CSN services when all of the following criteria are met. (1) There is a clearly identifiable, specific medical need for a nursing visit to provide nursing services, as described at 130 CMR 438.410(A), of more than two continuous hours; (2) The CSN services are medically necessary to treat an illness or injury in accordance with 130 CMR 438.410; and (3) Prior authorization is obtained by the CSN agency in accordance with 130 CMR 438.411. (C) Clinical Eligibility for Complex Care Assistant Services. A member is clinically eligible for MassHealth coverage of complex care assistant services when (1) they are found eligible for CSN services as described at 130 CMR 438.410(B); (2) services described at 130 CMR 438.415(C)(3)(a)2. may be safely performed by a complex care assistant; and (3) services are not duplicative of other services the member is receiving. (D) Member Must Be under the Care of a Physician or Ordering Non-physician Practitioner. The MassHealth agency pays for CSN agency services only if the member’s physician or ordering non-physician practitioner certifies the medical necessity for such services on an established individual plan of care in accordance with 130 CMR 438.419(C). A member may receive CSN agency services only if the member is under the care of a physician or ordering non- physician practitioner. The physician or ordering non-physician practitioner providing the certification of medical necessity must not be a physician or ordering non-physician practitioner on the staff of, or under contract with, the CSN agency or related home health agency. (E) Safe Maintenance in the Community. The member’s physician, ordering non-physician, and CSN agency must determine that the member can be maintained safely in the community with medically appropriate CSN agency services. (F) Multiple-patient Care for CSN Services. The MassHealth agency pays for one nurse to provide CSN services simultaneously to more than one member, but not more than three members, if (1) the members have been determined by the MassHealth agency or its designee to meet the criteria listed at 130 CMR 438.410(A); (2) the members receive services in their place of residence and during the same time period; (3) the MassHealth agency or its designee has determined that it is appropriate for one nurse to provide nursing services to the members simultaneously; and (4) the CSN agency has received a separate prior authorization for each member as described at 130 CMR 438.411. (G) Limitations on Covered Services. The MassHealth agency pays for CSN agency services to a member who resides in a non-institutional setting, which may include, without limitation, a homeless shelter or other temporary residence or a community setting. The MassHealth agency does not pay for CSN agency services when a member is under the direct care of a hospital or emergency room, nursing facility, intermediate care facility, or any other institutional facility providing medical, nursing, rehabilitative, or related care. The MassHealth agency pays for CSN agency services when the CSN agency must accompany the member in transport to and from an institutional setting to ensure medical stability.