Service Limitations

(A) Diagnostic and Individual Treatment Services. The MassHealth agency pays for diagnostic and treatment services only when a licensed independent behavioral health clinician, as defined by 130 CMR 462.402, personally provides these services to the member or the member's family. The services must be provided to the member on an individual basis. (B) Multiple Visits on a Same Date of Service. The MassHealth agency pays for only one visit of a single type of service (except for diagnostics) provided to an individual member on one date of service. Return visits on the same date of service are not reimbursable. (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 provider 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 the provider for court testimony. (E) Family Consultation. The MassHealth agency pays for consultation with family, or other responsible persons who are not eligible members, 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. (2) The MassHealth agency does not pay for group therapy when it is performed as an integral part of a psychiatric day treatment services, or intensive outpatient program services. This page is reserved.