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 CRP-21 June 2006 TO: Chiropractors Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Chiropractor Manual (Coverage of Chiropractor Services for Members Aged 21 Years or Older) Due to a new state law, effective July 1, 2006, MassHealth will cover payment of chiropractor services for eligible members aged 21 years or older. This letter transmits an amendment to the chiropractor regulations that reflects this change. All other conditions of 130 CMR 441.000 and 450.000 still apply. These regulations were filed as emergency regulations, effective July 1, 2006. This transmittal letter, including the attached pages, and other publications issued by MassHealth are available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library. 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.) Chiropractor Manual Pages iv, vii, 4-1, and 4-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Chiropractor Manual Pages iv and vii — transmitted by Transmittal Letter CRP-15 Pages 4-1 and 4-2 — transmitted by Transmittal Letter CRP-18 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Chiropractor Manual Transmittal Letter CRP-21 Date 07/01/06 4. Program Regulations 441.401: Introduction 4-1 441.402: Definitions 4-1 441.403: Eligible Members 4-1 441.404: Provider Eligibility 4-2 441.405: Out-of-State Chiropractic Services 4-2 441.406: Reimbursable Services 4-3 441.407: Service Limitations 4-3 441.408: Referral Requirements 4-3 441.409: Radiology Services 4-4 441.410: Nonreimbursable Services 4-4 441.411: Payment for Services 4-5 441.412: Recordkeeping Requirements 4-5 441.413: Rates of Payment 4-6 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Chiropractor Manual Transmittal Letter CRP-21 Date 07/01/06 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For chiropractors, those matters are covered in 130 CMR Chapter 441.000, reproduced as Subchapter 4 in the Chiropractor Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-1 Chiropractor Manual Transmittal Letter CRP-21 Date 07/01/06 441.401: Introduction 130 CMR 441.000 establishes the requirements for the provision and payment of chiropractor services under MassHealth. All chiropractors participating in MassHealth must comply with MassHealth regulations, including but not limited to 130 CMR 441.000 and in 130 CMR 450.000. 441.402: Definitions The following terms used in 130 CMR 441.000 have the meanings given in 130 CMR 441.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 441.402 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 441.000 and in 130 CMR 450.000. Chiropractic Manipulative Treatment – the correction of misalignments, subluxations, or segmental joint dysfunction of the bony articulations of the vertebral column, the pelvis, and adjacent areas. Chiropractor – one who is licensed to practice chiropractic manipulation to correct interference with spinal nerves by adjusting the spinal column. Office Visit – a visit by a MassHealth member to a chiropractor's office for evaluation and management services. These services do not include chiropractic manipulative treatment. Primary Care Clinician (PCC) – a provider of managed care to MassHealth members. The PCC must meet the requirements of 130 CMR 450.118(B). The PCC must be a MassHealth-participating provider and must sign a PCC provider agreement with the MassHealth agency. Subluxation – a segmental joint dysfunction, misalignment, fixation, or abnormal spacing of the vertebrae. 441.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for chiropractor services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105 specifically states, for each coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of the 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) For information on verifying member eligibility and coverage type, see 130 CMR 450.107. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-2 Chiropractor Manual Transmittal Letter CRP-21 Date 07/01/06 441.404: Provider Eligibility The MassHealth agency pays only chiropractors who are participating in MassHealth on the date of service. Chiropractors must meet the following eligibility requirements. (A) In-State Providers. To be eligible to participate in MassHealth, an in-state chiropractor must: (1) be licensed by the Massachusetts Board of Registration of Chiropractors; (2) be an active MassHealth provider; and (3) participate in the Medicare program as a chiropractor. (B) Out-of-State-Providers. To be eligible to participate in MassHealth, an out-of-state chiropractor must: (1) obtain a MassHealth provider number and maintain active provider status; (2) participate in his or her own state's Medicaid program; (3) be currently licensed as a chiropractor in his or her own state, or in a state that does not license chiropractors, be legally authorized to perform the services of a chiropractor in that state; and (4) participate in the Medicare program as a chiropractor. 441.405: Out-of-State Chiropractor Services (A) The MassHealth agency pays out-of-state chiropractors for covered services provided to an eligible MassHealth member when the chiropractor practices in a community of Connecticut, Maine, New Hampshire, New York, Rhode Island, or Vermont that is within 50 miles of the Massachusetts border and he or she provides covered services to a member who resides in a Massachusetts community near the border of the chiropractor's state. The out-of-state chiropractor's office must be more accessible to the member than the office of an in-state chiropractor who participates in MassHealth. (B) Prior authorization is required from the MassHealth agency before a chiropractor whose office is located in a community more than 50 miles from the Massachusetts border may provide covered chiropractor services to a member. Prior authorization will not be granted if the MassHealth agency determines that the chiropractor's office is less accessible to the member than the office of any other chiropractor participating in MassHealth. All requests for prior authorization must be submitted in accordance with the instructions found in Subchapter 5 of the Chiropractor Manual. The MassHealth agency does not pay for covered services provided at a site more than 50 miles from the Massachusetts border unless the chiropractor obtains prior authorization from the MassHealth agency before the delivery of service. The MassHealth agency does not grant retroactive requests for prior authorization.