Utilization Management Program for Acute Inpatient Hospitals

(A) Introduction. 130 CMR 450.207 through 450.209 describes the Utilization Management Program for acute inpatient hospitals. The purpose of this program is to ensure that certain medical services for which the MassHealth agency pays are medically necessary and provided in the appropriate setting. To this end, the MassHealth agency conducts reviews before elective admissions (admission screening) and after discharge but before payment (prepayment review). The MassHealth agency also conducts utilization reviews of inpatient admissions and outpatient services on a postpayment basis pursuant to 130 CMR 450.237. The term “admitting provider” as used in 130 CMR 450.207 through 450.209 refers to the provider (for example, physician or dentist) who admits the member to the facility and who assumes primary responsibility for the member's care and the admitting provider's designee, where appropriate. The requirements of the Utilization Management Program detailed in 130 CMR 450.207 through 450.209 apply to both in-state and out-of-state hospitals. 2. Administrative Regulations (B) General Provisions (1) Appendix. The MassHealth agency has issued an appendix to the provider manual for each facility and admitting provider affected by the Utilization Management Program. This appendix contains a list of information the admitting provider must provide for each review, and the name, address, and telephone number of the MassHealth agency's agent for the Utilization Management Program. (2) Stipulations. The Utilization Management Program does not waive or replace any other MassHealth agency requirements, such as prior-authorization or consent-form requirements. (3) Payment Restrictions. (a) The MassHealth agency will pay the acute inpatient hospital for services subject to the Utilization Management Program only if the admitting provider has complied with the requirements in 130 CMR 450.207 through 450.209 and the service is medically or administratively necessary. (b) Payments are subject to all general conditions and restrictions of the MassHealth agency. (c) A provider may not bill the member for any medical care for which the MassHealth agency has denied payment due to the provider's failure to comply with the requirements of the Utilization Management Program. (4) Exceptions. Proposed admissions of the following members, are exempt from the requirements of the Utilization Management Program, regardless of admitting diagnosis: (a) members whose hospitalization is court-ordered; (b) members of the EAEDC Program; and (c) members for whom MassHealth is not the primary payer of the acute inpatient admission, including but not limited to members covered by an MCO, Accountable Care Partnership Plan, One Care Plan, SCO Plan, commercial insurance, or Medicare. However, if the primary payer denies coverage before the member is admitted or if the member has Medicare Part B only, the admission of the member is not exempt from the requirements of the Utilization Management Program.