Service Limitations

(A) Diagnostic and Treatment Services. The MassHealth agency pays for diagnostic and treatment services only when a professional staff member, as defined by 130 CMR 448.415, personally provides these services to the member or the member's family or personally consults with a professional outside of the center. The services must be provided to the member on an individual basis and are not reimbursable if they are an aspect of service delivery, as defined in 130 CMR 448.408(B). (B) Multiple Visits on a Same Date of Service. Services provided through an encounter rate will be paid by the MassHealth agency pursuant to 101 CMR 305.00: Rates for Community Behavioral Health Centers. The MassHealth agency pays only one encounter bundled rate for each member on one date of service. The MassHealth agency will pay for Adult Mobile Crisis Intervention, Youth Mobile Crisis Intervention, Adult Community Crisis Stabilization, Youth Community Crisis Stabilization, Certified Peer Specialists services, Peer Recovery Coach services, Recovery Support Navigator services, Community Support Program services, and Psychological Testing on the same date of service as the encountered bundled rate. The MassHealth agency will only pay for one of the following on a single date of service: Structured Outpatient Addiction Program, Enhanced Structured Outpatient Addiction Program, Intensive Outpatient Program, or the encounter bundled rate. (C) Multiple Therapies. The MassHealth agency pays for more than one mode of therapy used for a member during one week when it is clinically justified, and when any single approach has been shown to be necessary but insufficient. The need for multiple therapies must be documented in the member's record. (D) Case Consultation. (1) The MassHealth agency pays only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings. (2) The MassHealth agency pays for case consultation only when written communication and other non-reimbursable forms of communication clearly will not suffice. Such circumstances must be documented in the member's record. Such circumstances are limited to situations in which both the center and the other party are actively involved in treatment or management programs with the member (or family members) and where a lack of direct communication would impede a coordinated treatment program. (3) The MassHealth agency does not pay a center for court testimony. (E) Family Consultation. The MassHealth agency pays for consultation with family or other responsible persons who are not an eligible member, when such consultation is integral to the treatment of the member. (F) Group Therapy. (1) Payment is limited to one fee per group member with a maximum of 12 members per group regardless of the number of staff members present. (2) The MassHealth agency does not pay for group therapy when it is performed as an integral part of a psychiatric day treatment services. (3) The MassHealth agency does not pay for group therapy when it is performed as an integral part of intensive outpatient program services. (G) Psychological Testing. The MassHealth agency pays a center for psychological testing only when the conditions outlined in 130 CMR 411.000: Psychologist Services are met. This page is reserved