Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth All Provider Bulletin 188 May 2009 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Elimination of the PCC Plan Referral Requirement for Certain Services Background MassHealth is changing the list of services that require referral for a member enrolled in the Primary Care Clinician (PCC) Plan. Effective May 26, 2009, MassHealth PCCs will no longer need to issue a PCC referral for many of the services that currently require referral for their patients enrolled in the PCC Plan. Elimination of the PCC Referral Requirement for Certain Services MassHealth is eliminating the PCC Plan referral requirement for certain services. Eliminating the referral requirement for these services will decrease the administrative burden on providers while still supporting the role of the PCC in coordinating the care received by their patients who are enrolled in the PCC Plan. Payment for services remains subject to all conditions and restrictions of MassHealth, including but not limited to, the scope of covered services for a member’s coverage type, service limitations, and prior-authorization requirements. See 130 CMR 450.105 for a list of the services covered for each MassHealth coverage type and applicable program regulations for descriptions of covered services and specific service limitations. Prior- authorization requirements are described in 130 CMR 450.303, 450.144(A)(2), and applicable program regulations. MassHealth is expecting to amend the MassHealth administrative and billing regulations (130 CMR 450.000), which are contained in Subchapters 1 through 3 of all provider manuals, to implement these changes to the PCC Plan referral requirement. Additional Services That Do Not Require a PCC Referral In addition to the services that currently do not require a referral, the following services will not require a referral for dates of service on or after May 26, 2009. MassHealth expects to add these new exceptions to the list of services in 130 CMR 450.118 that do not require a referral. * all items and services described in the durable medical equipment services regulations (130 CMR 409.000); * annual gynecologic exams; * fluoride varnish administered by a physician or other qualified medical professional; * hearing instrument specialist services; * medical nutrition therapy/diabetes self-management training; * orthotics services; * oxygen and respiratory therapy equipment; * personal care services provided by personal care attendants for members in MassHealth’s consumer-directed PCA program; * prosthetic services; * radiology and other imaging services with the exception of magnetic resonance imaging (MRI), computed tomography (CT) scans, and positron emission tomography (PET) scans; and * tobacco cessation counseling services. As a reminder, when billing for services that have both a professional component and technical component, please use Modifier 26 when reporting the professional component and Modifier TC when reporting the technical component. The referral written for these services will be applied to the technical component only of the service. Therefore, providers performing the technical component of a nonemergency service requiring a PCC referral must continue to obtain a PCC referral. Providers performing the professional component only of a service do not need to obtain a PCC referral. PCCs Will Continue to Coordinate Care Even though this policy change decreases the number of services that require specialty and ancillary providers to seek and receive PCC referrals for members enrolled in the PCC Plan, MassHealth continues to encourage all specialty and ancillary providers to communicate and coordinate with the PCC Plan members’ PCC when delivering care to these members. MassHealth providers can identify a member’s PCC by checking the MassHealth Eligibility Verification System on the Provider Online Service Center or by calling MassHealth Customer Service at 1-800-841-2900. Questions If you have questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.