Commonwealth of Massachusetts MassHealth Provider Manual Series Radiation Oncology Center Manual Subchapter Number and Title Table of Contents Page iv Transmittal Letter ROC-1 Date 06/01/11 4. Program Regulations 436.401: Introduction ............................................................................. ... .......................... 4-1 436.402: Definitions ............................................................................. ... ............................ 4-1 436.403: Eligible Members ............................................................................. ... ................. 4-2 436.404: Provider Eligibility ............................................................................. ... ................ 4-2 436.405: Maximum Allowable Fees ............................................................................. ... .... 4-3 436.406: Individual Consideration ............................................................................. ... ....... 4-3 436.407: Prior Authorization................................................................ ... ............................. 4-4 436.408: Report Requirements…………………………………………………………….. 4-4 (130 CMR 436.409 through 436.412 Reserved) 436.413: Payment...................................................................... ... ........................................ 4-5 436.414: Levels of Physician Supervision ……….. ............................................................ 4-5 436.415: Covered Services………………………………………………………………… 4-5 436.416: Noncovered Services..................................................................... ... ..................... 4-5 436.417: Recordkeeping Requirements................................................................. ... ............ 4-6 436.418: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services…… 4-6 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 436.000) Page 4-1 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 436.401: Introduction 130 CMR 436.000 establishes the requirements for the provision and reimbursement of radiation oncology services under MassHealth. The MassHealth agency pays for radiation oncology services that are medically necessary and appropriately provided in accordance with 130 CMR 450.204. All radiation oncology centers participating in MassHealth must comply with all MassHealth regulations including, but not limited to, 130 CMR 436.000 and 450.000. 436.402: Definitions The following terms used in 130 CMR 436.000 have the meanings given in 130 CMR 436.402, unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 436.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 436.000 and in 450.000. Direct Supervision — the physician is present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not require that the physician be present in the room when the procedure is performed. General Supervision — the procedure is furnished under the physician’s overall direction and control, but the physician is not necessarily required during the performance of the procedure. Non-Physician Personnel — technicians, employed or contracted by the radiation oncology center, whose function is to perform the technical component of a given procedure. Personal Supervision — a physician is physically in the room during the performance of the procedure. Referring Physician — a physician who requests or orders the service but does not necessarily perform the service. Supervising Physician — the physician responsible for the personal, direct or general supervision of the testing performed, the quality of the testing performed, the proper operation and calibration of the equipment used to perform tests, and the actions of non-physician personnel who use the equipment. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 436.000) Page 4-2 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 436.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for services provided by radiation oncology centers to MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105 specifically states for each MassHealth coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106. (B) Member Eligibility and Coverage Type. For information on verifying member eligibility and coverage type, see 130 CMR 450.107. 436.404: Provider Eligibility The MassHealth agency makes payment for services, described in 130 CMR 436.000, only to eligible providers of radiation oncology services who are participating in MassHealth on the date of service. The participating provider is responsible for the quality of all services for which payment is claimed, the accuracy of such claims, and compliance with all regulations applicable to radiation oncology services under MassHealth. In order to claim payment, the participating provider must be the radiation oncology center that actually performed the service. A radiation oncology center must have one or more supervising physicians who are responsible for the personal, direct, or general supervision of the facility and its personnel in accordance with Medicare requirements at 42 CFR 410.323(b)(3), the operation and calibration of the equipment, and the quality of the testing performed. (A) In State. To be eligible to participate as a MassHealth provider, a radiation oncology center must (1) be located and doing business in the Commonwealth of Massachusetts; (2) operate under a clinic license issued by the Massachusetts Department of Public Health (DPH), in accordance with regulations at 105 CMR 140.000. (Providers operating as a satellite location under a Massachusetts DPH hospital license, or otherwise have Medicare provider-based status under 42 CFR 413.65, do not meet this requirement.); (3) obtain a current determination of need or acceptable substitute such as a physician’s exemption letter issued by the Massachusetts Department of Public Health, to provide radiation therapy services; (4) employ to perform, oversee, and direct all care provided at the center one or more physicians licensed by Commonwealth of Massachusetts as a radiation oncologist, nuclear medicine provider, or radiologist; (5) ensure that non-physician medical technicians providing services are licensed by the Commonwealth of Massachusetts to provide such services in accordance with regulations at 105 CMR 120.000; and (6) participate in the Medicare program as a radiation therapy provider. (B) Out of State. A radiation oncology center located outside of Massachusetts that does not otherwise meet the requirements of 130 CMR 436.404(A) may participate in MassHealth if it meets the requirements of 130 CMR 436.404(A)(6), 450.109, and the following: (1) employs to perform, oversee, and direct all care provided at the center one or more physicians licensed as a radiation oncologist, nuclear medicine provider, or radiologist in the same state the radiation oncology center is located and operating; (2) ensures that non-physician medical technicians providing services are licensed in the same state in which the radiation oncology center is located and operating; and (3) participates in the Medicare program as a radiation therapy provider. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 436.000) Page 4-3 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 436.405: Maximum Allowable Fees (A) The MassHealth agency pays for radiation oncology center services with rates set by the Massachusetts Division of Health Care Finance and Policy (DHCFP), subject to the conditions, exclusions, and limitations set forth in 130 CMR 436.000. (B) The maximum allowable fee is full compensation for the radiation oncology service and any related administrative or supervisory duties in connection with the services, regardless of where the service was provided. 436.406: Individual Consideration (A) Some services listed in Subchapter 6 of the Radiation Oncology Center Manual are designated "I.C.," an abbreviation for individual consideration. Individual consideration means that a fee has not been established for these services. Payment for an individual-consideration service is determined by the MassHealth agency's professional advisers, based on the radiation oncology centers descriptive report of the services furnished, which must be included with the claim. (B) If a service is not listed in Subchapter 6 of the Radiation Oncology Center Manual, a radiation oncology center may submit a claim by using the appropriate "unlisted service" service code. Payment for an unlisted service is determined by individual consideration, based on the center’s descriptive report of the service, which must be included with the claim. (C) The MassHealth agency considers the following factors when determining the appropriate payment for an individual-consideration service: (1) the amount of time required to perform the service; (2) the degree of skill required to perform the service; (3) the policies, procedures, and practices of other third-party insurers, both governmental and private; (4) prevailing professional ethics and accepted customs of the diagnostic testing and radiation oncology community; and (5) other standards and criteria as may be adopted by DHCFP or the MassHealth agency. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 436.000) Page 4-4 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 436.407: Prior Authorization (A) The MassHealth agency requires the radiation oncology center to obtain prior authorization for services that are designated "P.A." in the service descriptions listed in Subchapter 6 of the Radiation Oncology Center Manual. (B) Prior authorization determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment such as member eligibility or resort to health insurance payment. (C) All requests for prior authorization must be submitted in accordance with the instructions found in Subchapter 5 of the Radiation Oncology Center Manual. No payment will be made for such services unless prior authorization has been obtained from the MassHealth agency before the delivery of service. The MassHealth agency will not grant retroactive prior-authorization requests. 436.408: Report Requirements A general written report or a discharge summary must accompany the claim for payment for any service that is listed in Subchapter 6 of the Radiation Oncology Center Manual as requiring a report or individual consideration (I.C.), or if the code is for an unlisted service. This report must be sufficiently detailed to enable the MassHealth agency to assess the extent and nature of the service. (436.409 through 436.412 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 436.000) Page 4-5 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 436.413: Payment (A) Global Fee. Payment for a diagnostic procedure performed at a radiation oncology center will include facility costs, technical costs, and professional costs. (B) Terminated Procedures. Upon review, the MassHealth agency may pay for procedures that were unable to be completed after the procedure was initiated. 436.414: Levels of Physician Supervision Radiation oncology centers must provide the appropriate level of physician supervision for each procedure in accordance with Medicare requirements at 42 CFR 410.323(b)(3). The definition of each level of physician supervision is set forth in 130 CMR 436.402. 436.415: Covered Services The MassHealth agency pays for radiation oncology services necessary for the diagnosis, detection, and treatment of disease, and for the maintenance of the health of MassHealth members, subject to all restrictions and limitations described in MassHealth regulations at 130 CMR 436.000 and 450.000. 436.416: Noncovered Services The MassHealth agency does not pay for the following services: (A) services performed for experimental or investigational purposes, or that are themselves experimental or investigational; and (B) services provided by a physician who individually or through a group practice has contractual arrangements with an acute, chronic, or rehabilitation hospital, medical school, or other medical institution that involve a salary, compensation in kind, teaching, research, or payment from any other source, if such payment would result in dual compensation for professional, supervisory, or administrative services related to member care. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 436.000) Page 4-6 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 436.417: Recordkeeping Requirements (A) The radiation oncology center is responsible for ensuring the medical necessity of the services and maintaining test results in the patient’s health record. (B) Radiation oncology centers must maintain a medical-record system promoting quality and confidential patient care in accordance with Massachusetts Department of Public Health regulations at 105 CMR 140.000. This system must collect and retain data in a comprehensive and efficient manner and permit the prompt retrieval of information. Accurate and complete medical records must be maintained for each member receiving testing services from the radiation oncology center. The data maintained in the member's medical record must also be sufficient to justify any further diagnostic procedures. The medical record must be clear and legible, and readily accessible to health care practitioners and the MassHealth agency. The medical record must be maintained by the radiation oncology center for at least six years. (C) The medical record must contain, at a minimum, the following information: (1) the member's name, address, telephone number, date of birth, and MassHealth identification number; (2) the date of service; (3) the name, title and signature of the referring physician; (4) a written order for the tests or treatment to be performed; (5) the name, title, and signature of the person performing the service; (6) the name of the supervising physician; (7) pertinent findings on examination; and (8) the tests and treatment performed and the respective results. 436.418: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services The MassHealth agency pays for all medically necessary radiation oncology center services for EPSDT-eligible members in accordance with 130 CMR 450.140 et seq., without regard to service limitations described in 130 CMR 436.000, and with prior authorization. REGULATORY AUTHORITY 130 CMR 436.000: M.G.L. c. 118E, §§ 7 and 12.