Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter AOH-15 August 2007 TO: Acute Outpatient Hospitals and Hospital-Licensed Health Centers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Acute Outpatient Hospital Manual (Revised Provider Regulations about Copayments) Effective January 1, 2007, MassHealth has eliminated the copayment on emergency screening that acute hospitals were previously allowed to collect when they delivered nonemergency services to members in the emergency department. As of January 1, 2007, acute hospitals should no longer charge MassHealth members copayments for such services. This change is a result of new requirements enacted in the federal Deficit Reduction Act of 2005, which became effective January 1, 2007. This also affects regulations in 130 CMR 450 (for all generic providers) and in the Chronic Disease and Rehabilitation Outpatient Hospital Manual. Similar regulation changes are concurrently being promulgated to reflect this. If you have any questions about the information in this transmittal letter 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. NEW MATERIAL (The pages listed here contain new or revised language.) Acute Outpatient Hospital Manual Pages iv, 4-13, and 4-14 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Pages iv, 4-13, and 4-14 — transmitted by Transmittal Letter AOH-10 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Acute Outpatient Hospital Manual Transmittal Letter AOH-15 Date 01/01/07 4. Program Regulations 410.401: Introduction........................................................................................................... 4-1 410.402: Definitions............................................................................................................. 4-1 410.403: Eligible Members ................................................................................................. 4-5 410.404: Provider Eligibility................................................................................................ 4-5 410.405: Noncovered Services............................................................................................. 4-6 410.406: Payment................................................................................................................. 4-7 410.407: Certification........................................................................................................... 4-8 410.408: Prior Authorization................................................................................................ 4-9 410.409: Recordkeeping (Medical Records) Requirements................................................. 4-10 410.410: Assurance of Member Rights................................................................................ 4-13 410.411: Emergency Services.............................................................................................. 4-14 410.412: Utilization Management Program and Mental Health and Substance Abuse Admission Screening Requirements.................................................................. 4-14 410.413: Medical Services Required on Site at a Hospital-Licensed Health Center............ 4-15 410.414: Observation Services............................................................................................. 4-16 (130 CMR 410.415 through 410.419 Reserved) 410.420: Tobacco Cessation Services ................................................................................. 4-17 (130 CMR 410.421 through 410.430 Reserved) 410.431: Sterilization Services: Introduction...................................................................... 4-21 410.432: Sterilization Services: Informed Consent ............................................................ 4-22 410.433: Sterilization Services: Consent Form Requirements............................................ 4-23 410.434: Abortion Services: Reimbursable Services.......................................................... 4-24 410.435: Abortion Services: Certification for Payable Abortion Form.............................. 4-25 410.436: Abortion Services: Out-of-State Abortions.......................................................... 4-27 410.437: Family Planning Services...................................................................................... 4-27 (130 CMR 410.438 through 410.440 Reserved) 410.441: Early Intervention Program Services..................................................................... 4-29 410.442: Home Health Agency Services.............................................................................. 4-29 410.443: Adult Day Health Program Services..................................................................... 4-30 410.444: Adult Foster Care Services.................................................................................... 4-30 410.445: Psychiatric Day Treatment Program Services....................................................... 4-31 410.446: Dental Services...................................................................................................... 4-31 (130 CMR 410.447 through 410.450 Reserved) 410.451: Therapist Services: Covered Services.................................................................. 4-32 410.452: Therapist Services: Service Limitations............................................................... 4-33 410.453: Therapist Services: Recordkeeping Requirements............................................... 4-33 (130 CMR 410.454 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 410.000) Page 4-13 Acute Outpatient Hospital Manual Transmittal Letter AOH-15 Date 01/01/07 (a) visual acuity; (b) distance vision and near vision; (c) cover test; (d) visual skills; (e) tonometry; and (f) biomicroscopy. (J) For laboratory services, in addition to the applicable information required in 130 CMR 410.409(D) above, the member's medical record must contain a suitable record of each specimen and laboratory test result for at least six years from the date on which the results were reported to the prescriber (see 130 CMR 410.458): (1) the name and any other means of identification of the person from whom the specimen was taken; (2) the name of the prescriber or laboratory that submitted the specimen; (3) the authorized requisition or order, or both; (4) the location where the specimen was taken, if other than the hospital outpatient department; (5) the date on which the specimen was collected by the prescriber or laboratory; (6) the date on which the specimen was received in the laboratory; (7) the condition of unsatisfactory specimens when received (for example, broken, leaked, hemolyzed, turbid, or insufficient sample size); (8) the date on which the test was performed; (9) the test name and the results of the test, or the cross-reference to results and the date of reporting; and (10) the name and address of the laboratory to which the specimen was referred, if applicable. 410.410: Assurance of Member Rights No provider shall use any form of coercion in the provision of any services (for example, abortion, sterilization, and family planning). Neither the MassHealth agency nor any provider, nor any agent or employee of a provider, shall mislead any member into believing that a decision to receive any services reimbursable under these regulations will adversely affect the member's entitlement to benefits or services for which the member would otherwise be eligible. The MassHealth agency has strict requirements for the confidentiality of patient records for all medical services reimbursable under MassHealth. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 410.000) Page 4-14 Acute Outpatient Hospital Manual Transmittal Letter AOH-15 Date 01/01/07 410.411: Emergency Services (A) The MassHealth agency pays for emergency services provided in a hospital emergency room only when such services are medically necessary and the necessity is fully documented in the member's medical record. (B) For services provided in the emergency department, handwritten or time-stamped documentation of the length of the member's stay in the emergency room must be kept in the member's record or on an easily accessible hospital log. 410.412: Utilization Management Program and Mental Health and Substance Abuse Admission Screening Requirements (A) Utilization Management Program. The MassHealth agency pays for procedures and hospital stays that are subject to the Utilization Management Program only if the applicable requirements of the program as described in 130 CMR 450.207 through 450.211 are satisfied. Appendix H of the Acute Outpatient Hospital Manual contains the name, address, and telephone number of the contact organization for the Utilization Management Program and describes the information that must be provided during the review process. (B) Mental Health and Substance Abuse Admissions. The MassHealth agency pays for mental health and substance abuse services provided in an acute or nonacute inpatient setting only if the admitting provider has satisfied the screening requirements at 130 CMR 450.125.