Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Limited Services Clinics Bulletin 1 May 2009 TO: Limited Services Clinics Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: New MassHealth Limited Services Clinics Provider Type Background The Massachusetts Department of Public Health (DPH) has begun licensing Limited Services Clinics (LSCs) under its regulations at 105 CMR 140.1000. Pursuant to these regulations, LSCs may not provide treatment to children younger than 24 months old. MassHealth will begin enrolling MassHealth-qualified LSCs within its nurse practitioner provider type, effective for dates of service on or after June 1, 2009. Providers who wish to enroll as a MassHealth LSC must meet the following eligibility criteria and should contact MassHealth Customer Service as specified under the Provider Enrollment section (below) to request an enrollment package. Eligibility Criteria To be eligible for participation as a MassHealth LSC provider, the clinic must meet the 130 CMR 433.433 MassHealth eligibility criteria for nurse practitioner services. MassHealth LSC providers must also meet the following MassHealth and DPH requirements: 1. be located and doing business in the Commonwealth of Massachusetts; 2. operate under a clinic license issued by the DPH, in accordance with regulation 105 CMR 140.000; 3. employ a person to administer the clinic and ensure that it complies with applicable Massachusetts and federal statutes and regulations; 4. employ a professional services director who shall be responsible for clinical services provided at the clinic. The professional services director must be a health care professional with academic training and experience in direct patient care and must be qualified to direct the services provided by the clinic. The professional services director must ensure that the treatment and care provided are adequate and appropriate for the needs of MassHealth members (The same individual may serve as the clinic administrator and the professional services director, if this individual meets the requirements for both positions and can adequately carry out the duties of both positions.); (continued on next page) Eligibility Criteria 5. (cont.) employ one or more physicians licensed by the Commonwealth of Massachusetts, as necessary, to provide or supervise all services involving the practice of medicine provided by the clinic. At least one physician must be either on site or on call during all hours of operation; 6. ensure nurse practitioners providing services are licensed by the Commonwealth of Massachusetts Board of Registration in Nursing to perform such services. Pursuant to 130 CMR 433.433(C)(2), each nurse practitioner must have a current collaborative arrangement with a physician(s) including written clinical guidelines and a written agreement signed by the Nurse Practitioner and the collaborating physician(s); 7. submit to MassHealth as part of the application process all versions of written collaborative agreements that are used for nurse practitioners at the site. The LSC provider must maintain on-site all signed collaborative agreements for each nurse practitioner practicing at that site. The LSC provider must submit signed collaborative agreements to MassHealth upon request. Following enrollment, the LSC provider must submit to MassHealth any updates or changes to all versions of collaborative agreements over time; 8. must make, for purposes of 130 CMR 433.433(C)(2), the clinical guidelines for each LSC location available for review by MassHealth staff at the time of application for enrollment as a MassHealth provider and upon request thereafter. Following enrollment, any updates or changes to the clinical guidelines over time must be maintained on file and available for review upon request by MassHealth; 9. comply with the recordkeeping provisions of 130 CMR 450.205, which apply specifically to the collaborative agreements and clinical guidelines. In particular, LSCs must maintain obsolete versions of collaborative agreements and clinical guidelines in accordance with 130 CMR 450.205; and 10. ensure that the qualifications of its practitioners extend to appropriate training for the age range of MassHealth members treated at the clinic. Provider Enrollment Providers who wish to participate as a MassHealth LSC must complete an application. Applicants should contact MassHealth Customer Service at 1-800-841-2900 or by e-mail at providersupport@mahealth.net to request an enrollment application package or additional information about the MassHealth enrollment process. Each location of an LSC must apply separately. (continued on next page) Vaccines Provided in a Limited Services Clinic Free-of-charge vaccines supplied by the DPH are not reimbursable by MassHealth. See 130 CMR 433.413(C). Under the same provision, MassHealth also will not reimburse an LSC for a vaccine if its cost to the LSC is $1.00 or less. Information about the availability of DPH-supplied vaccines can be found at the following DPH Web sites: www.mass.gov/dph; and www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/vaccine_availability childhood.pdf. MassHealth will reimburse LSCs for vaccines that are not supplied by DPH and that are listed in the following section of this bulletin. According to DPH regulations at 105 CMR 140.1000, no LSC may provide childhood immunizations (excluding influenza vaccine) unless such clinic is a satellite of or otherwise affiliated with a licensed health care practitioner or entity that provides primary care to the patient seeking immunization. MassHealth Limited Services Clinic Service Codes The following service codes are the only payable codes for MassHealth LSC providers. Service Code Service Description 69210 Removal impacted cerumen (separate procedure), one or both ears 87650 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique 87804 Infectious agent antigen detection by immunoassay with direct optical observation; Influenza 87880 Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) 90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) (continued on next page) MassHealth Limited Service Services Clinic Code (cont.) Service Description Service Codes 90632 Hepatitis A vaccine, adult dosage, for intramuscular use (covered for adults 19 years or older; available free of charge through the Massachusetts Immunization Program for children aged two through18 years) 90655 Influenza virus vaccine, split virus, preservative free, when administered to children six-35 months of age, for intramuscular use (use only for children 24-35 months of age) 90656 Influenza virus vaccine, split virus, preservative free, when administered to individuals three years and older, for intramuscular use 90658 Influenza virus vaccine, split virus, when administered to individuals three years of age and older, for intramuscular use 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals seven years or older, for intramuscular use (covered for adults 19 years or older; available free of charge through the Massachusetts Immunization Program for children seven through18 years of age) 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals two years or older, for subcutaneous or intramuscular use (covered for adults 19 years or older; available free of charge through the Massachusetts Immunization Program for children aged two through18 years) 90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use 90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W- 135 (tetravalent), for intramuscular use (covered for adults 19 years and older; available free of charge through the Massachusetts Immunization Program for children aged two through 18) I.C. (claim requires individual consideration) 90746 Hepatitis B vaccine, adult dosage, for intramuscular use 92567 Tympanometry (impedance testing) 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key (continued on next page) MassHealth Limited Service Services Clinic Code (cont.) Service Description Service Codes components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians (or nurse practitioners) typically spend 10 minutes face-to- face with the patient and/or family. 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians (or nurse practitioners) typically spend 20 minutes face-to-face with the patient and/or family. 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians (or nurse practitioners) typically spend 30 minutes face-to-face with the patient and/or family. 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Physicians (or nurse practitioners) typically spend 10 minutes face-to-face with the patient and/or family. (continued on next page) MassHealth Limited Service Services Clinic Code (cont.) Service Codes Service Description 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians (or nurse practitioners) typically spend 15 minutes face-to-face with the patient and/or family. Service Limitations All LSCs participating in MassHealth must comply with the regulations governing MassHealth, including but not limited to 130 CMR 450.000. MassHealth members who are participants in the Primary Care Clinician (PCC) Plan do not require a referral from a PCC for LSC services. In addition, according to MassHealth regulations at 130 CMR 433.413(A), a LSC may bill for an office (clinic) visit or a treatment/procedure, but may not bill for both categories for the same member on the same date when the office (clinic) visit and the treatment or procedure are performed in the same location. According to 130 CMR 433.413(B), when an immunization or injection is the primary purpose of an office (clinic) visit, the LSC may only bill for the injectable material and its administration. However, when the immunization or injection is not the primary purpose of the office (clinic) visit, the LSC may bill for both the visit and the injectable material, but not for its administration. Member Eligibility According to MassHealth regulations at 130 CMR 450.231, a provider is responsible for verifying member eligibility before the delivery of a service. Providers must also ensure that the services provided are covered under the individual’s MassHealth coverage type before service delivery. According to DPH regulations at 105 CMR 140.1000, no LSC may provide treatment to children younger than 24 months old. Information relating to member eligibility checks and coverage types is available on the MassHealth Web site at www.mass.gov/masshealth. Click on Information for MassHealth Providers. Billing Instructions This bulletin, MassHealth companion guides for electronic transactions, and paper claim billing guides are available on the MassHealth Web site (continued on next page) Billing Instructions (cont.) at www.mass.gov/masshealth. Click on the link to MassHealth Regulations and Other Publications, and then Provider Library. Recordkeeping (Medical Records) Requirements LSCs are governed by the MassHealth recordkeeping provisions at 130 CMR 450.205, 130 CMR 433.409, and the DPH regulations at 105 CMR 140.302. In addition, according to DPH regulations at 105 CMR 140.1001, the LSC must provide a copy of the medical record to the MassHealth member at the end of the visit or as soon as available, and, with the member’s consent, provide a facsimile or electronically transmitted copy of the medical record of the visit to the member’s primary care practitioner, if any. Such copies or transmissions must be provided at no charge to the member. Fee Schedule Service codes noted above, as payable, are paid at the current Division of Health Care Finance and Policy (DHCFP) fee schedule at 114.3 CMR 17.00: Medicine; 114.3 CMR 16.00: Surgery and Anesthesia Services; and 114.3 CMR 20.00: Clinical Laboratory Services. For 114.3 CMR 17.00: Medicine; and 114.3 CMR 16.00: Surgery and Anesthesia Services; payment for services provided by eligible licensed Nurse Practitioners is 85% of the fees contained therein. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy (DHCFP) regulations for free at www.mass.gov/dhcfp. You may also purchase a paper copy of the regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. The regulation titles are 114.3 CMR 17.00: Medicine; 114.3 CMR 16.00: Surgery and Anesthesia Services; and 114.3 CMR 20.00: Clinical Laboratory Services. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Boston, MA 02116 Two Boylston Street Telephone: 617-988-3100 www.mass.gov/dhcfp Questions If you have any 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.