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 PIH-16 January 2009 TO: Psychiatric Inpatient Hospitals Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Psychiatric Inpatient Hospital Manual (Implementation of the Child and Adolescent Needs and Strengths Tool) This letter transmits revisions to the psychiatric inpatient hospital regulations to implement the Child and Adolescent Needs and Strengths (CANS) tool. The CANS is a standardized behavioral-health assessment tool that MassHealth is implementing as part of the Children’s Behavioral Health Initiative (CBHI) for members under the age of 21. These regulations are effective December 26, 2008. Overview of the MassHealth CANS Requirement MassHealth providers who furnish behavioral-health services to MassHealth members under the age of 21 are required to ensure that certain clinicians are certified every two years, according to the process established by MassHealth, to use the CANS, and that those clinicians complete the CANS when the member is discharged from a behavioral-health inpatient setting. For each CANS conducted, these providers are required to document the data collected during the discharge planning process in the member’s medical record and report it to MassHealth in a specified manner and format. Description of the CANS Tool MassHealth has developed two versions of the CANS tool: “CANS Birth through Four” and “CANS Five through Twenty.” In addition to the CANS assessment questions, both forms allow the clinician to record the determination of whether the member has a serious emotional disturbance (SED). Providers can access the two CANS forms, as well as frequently asked questions relating to them, on the MassHealth CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. Click on Information for Providers. The link for the CANS tool is under the first heading. The CBHI Web site also includes a bibliography of published papers and other resources on the CANS approach. CANS Requirements for Psychiatric Inpatient Hospitals Psychiatric inpatient hospitals must complete the CANS during the discharge planning process for members under the age of 21. The CANS must be completed by one of the following clinicians types certified in the CANS: * psychiatrists and psychiatric residents; * psychologists who have a specialization in clinical or counseling psychology; * social workers who have a master’s degree in social work from an accredited educational institution; * psychiatric nurse mental-health clinical specialists; or * counselors who have a master’s degree in counseling education, counseling psychology, or rehabilitation psychology from an accredited educational institution. The medical record of each member under the age of 21 must include a CANS completed during the discharge planning process. In addition, for each CANS conducted, psychiatric inpatient hospitals must ensure that the data collected is reported to MassHealth in the format that is specified in the section entitled “CANS Reporting Requirements: “Paper CANS” and the Web-based Massachusetts CANS Application.” CANS Certification and Training Requirements Clinicians who are required to use the CANS must be certified every two years by passing an online CANS certification examination. Bachelors-level direct service providers or paraprofessionals will not be trained or certified in the CANS. Certified clinicians can use both versions of the Massachusetts CANS: “CANS Birth through Four” and “CANS Five through Twenty.” MassHealth is offering online and in-person training opportunities to assist clinicians with the certification process. The in-person training is being conducted by the University of Massachusetts Medical School on various dates across the state. Participation in both the in-person and online training will be free of charge and will include free Continuing Education Units (CEUs). Participation is voluntary, but encouraged. It is not necessary to participate in training in order to take the certification exam. Information about the CANS training and certification exam can be found on the Web at https://masscans.ehs.state.ma.us. This Web site provides access to the online training, the online certification exam, and the schedule of the in- person training sessions. For more information about CANS training or certification please contact the Massachusetts CANS Training Center by calling 508-856-1016 or e-mailing Mass.CANS@umassmed.edu. CANS Reporting Requirements: “Paper CANS” and the Web-based Massachusetts CANS Application MassHealth has developed a new Web-based application that permits providers to enter and view CANS data in a secure environment, subject to consent by the member, his or her custodial parent, or other authorized individual. The CANS application is accessible through the Executive Office of Health and Human Services (EOHHS) Virtual Gateway (VG) Web portal. MassHealth is rolling out the online CANS application in two stages. The first release was in December 2008. It allows users to develop familiarity with the application and asks users to document certain member demographic information and answer the questions that determine if the member has a serious emotional disturbance (SED). The second release, which is expected in the spring of 2009, will add the rest of the assessment questions from the two versions of the CANS tool. With the CANS application available online, psychiatric inpatient hospitals are required to use this application each time the CANS is completed or updated to satisfy their CANS data reporting requirements. Until the second release of the online CANS application, which is expected in the spring of 2009, the CANS must be completed on paper and be included in the member’s medical record. Once the second release occurs, providers can choose to include a copy of the CANS in either an electronic or paper form in the member’s medical record. However, providers must be sure to exercise one of these options. At no point should a CANS form be mailed to EOHHS or MassHealth. The CANS forms are available at the MassHealth CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. Click on Information for Providers. The link for the CANS tool is under the first heading. This link will take you to PDF and RTF (for screen readers for the visually disabled) versions of the two CANS forms. Psychiatric inpatient hospitals can obtain updated information about the release schedule of the CANS application on the CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. Providers should check this site regularly for updated information. In order to use the online CANS application, psychiatric inpatient hospitals must ensure that the facility is enrolled with the VG and that each clinician who will be entering and viewing data in the CANS application has his or her own VG user ID. In addition, the CANS application will allow data entry operators to perform certain functions on behalf of clinicians. Each data entry operator also needs his or her own VG user ID. Enrollment with the VG for other business applications, such as STARS or EIM/EIS, does not satisfy this requirement. For assistance in the process in obtaining access to the CANS application, psychiatric inpatient hospitals should send the following information to VirtualGatewayCBHI@state.ma.us: * the name of the facility or organization; * the name, address, phone, and e-mail address for a CANS point-of-contact at the organization who is being identified to work with the Virtual Gateway Deployment Unit; * a statement indicating whether or not the organization has access to the VG Web portal (yes or no); * the number of clinicians who need access to the CANS application; and * a statement indicating whether or not anyone in the organization has completed the CANS training. (If yes, provide the number of individuals who have completed the training.) If you have any comments or concerns about the VG enrollment process or technical questions about the CANS application, please send them to VirtualGatewayCBHI@state.ma.us. MassHealth is developing job aids and interactive flash files for the CANS application. There will be a job aid explaining how to log onto the application. Also, there will be separate job aids for clinicians, data entry operators, and provider organization staff to help them use and navigate the various functions that they have access to in the system. The job aids will be available on the CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. In addition, for clinicians registered on the VG, the job aids and flash files will be transmitted electronically from the VG Team to provide instruction on the application. Other Changes to the Regulations Other revisions to the psychiatric inpatient hospital regulations add language about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. Specifically, pursuant to 130 CMR 450.144(A), a provider may request prior authorization for any medically necessary service for a MassHealth Standard or CommonHealth member under the age of 21, even if it is not otherwise covered under the psychiatric inpatient hospital regulations. Contact Numbers If you need technical assistance with the VG, you may contact VG Customer Assistance at 1-800-421-0938, ext. 5. If you have questions about CANS training or certification, contact the Massachusetts CANS Training Center at 508-856-1016 or e-mail your questions to Mass.CANS@umassmed.edu. 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.) Psychiatric Inpatient Hospital Manual Pages iv and 4-1 through 4-12 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Psychiatric Inpatient Hospital Manual Page iv — transmitted by Transmittal Letter PIH-13 Pages 4-1 through 4-4 and 4-7 through 4-12 — transmitted by Transmittal Letter PIH-11 Pages 4-5 and 4-6 — transmitted by Transmittal Letter PIH-14 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 4. PROGRAM REGULATIONS 425.401: Introduction 4-1 425.402: Definitions 4-1 425.403: Eligible Members 4-3 425.404: Exclusion of MassHealth Managed Care Members 4-3 425.405: Provider Eligibility 4-3 425.406: Admission Criteria for Members under Age 21 4-4 425.407: Admission Criteria for Members Aged 21 or Over 4-4 425.408: Payment Methodology 4-5 425.409: Nonreimbursable Services 4-5 425.410: Service Limitations 4-6 425.411: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 4-6 425.412: Child and Adolescent Needs and Strengths (CANS) Certification 4-6A 425.413: Child and Adolescent Needs and Strengths (CANS) Data Reporting 4-6A (130 CMR 425.414 Reserved) 425.415: Notification and Right of Appeal 4-6B 425.416: Treatment Plan 4-6B 425.417: Conditions for Continuing Care 4-7 425.418: Discharge Planning 4-7 425.419: Utilization Review 4-9 425.420 Reimbursable Administrative Days 4-10 425.421 Nonreimbursable Administrative Days 4-10 425.422: Periodic Medical Review 4-11 425.423: Recordkeeping Requirements 4-11 425.424: Confidentiality 4-12 456.601: Personal Needs Allowance Account 4-13 456.602: Management of the PNA Account 4-13 456.603: Autonomy of PNA Accounts 4-13 456.604: PNA Recordkeeping Requirements 4-13 456.605: Petty Cash in the Facility 4-14 456.606: Assurance of Financial Security 4-14 456.607: Availability of the PNA Records to MassHealth Agency Personnel 4-15 456.608: Member Signature 4-15 456.609: Notification of Account Balance 4-15 456.610: Availability of the PNA Records to Members 4-15 456.611: PNA Funds of a Member Transferred to Another Facility 4-15 456.612: PNA Funds of a Member Discharged to the Community 4-15 456.613: Member Is Transferred to a Hospital and Does Not Return to the Facility 4-16 456.614: Death of a Member 4-16 456.615: Annual Accounting to the MassHealth Agency of the PNA Balance 4-17 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-1 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 425.401: Introduction 130 CMR 425.000 contains regulations governing psychiatric inpatient hospital services under MassHealth. All psychiatric inpatient hospitals participating in MassHealth must comply with the MassHealth regulations, including, but not limited to, MassHealth regulations at 130 CMR 425.000 and 130 CMR 450.000. 425.402: Definitions The following terms used in 130 CMR 425.000 will have the meanings given in 130 CMR 425.402 unless the context clearly requires a different meaning. Activities of Daily Living — the quality or process of accomplishing everyday needs, including bathing, dressing and grooming, eating, transferring, ambulation, and toileting. Administrative Day — a day of inpatient hospitalization on which a member's care needs can be met in a less intensive setting than a psychiatric inpatient hospital, as defined in 130 CMR 425.402, and on which a member is clinically ready for discharge, but an appropriate institutional or noninstitutional setting is not readily available. Case Manager — an area-based coordinator of services employed by the Department of Mental Health (DMH) or, where appropriate, the Department of Children and Families (DCF), the Department of Youth Services (DYS), or the Department of Mental Retardation (DMR). Child and Adolescent Needs and Strengths (CANS) — a tool that provides a standardized way to organize information gathered during behavioral-health clinical assessments. A Massachusetts version of the tool has been developed and is intended to be used as a treatment decision support tool for behavioral- health providers serving MassHealth members under the age of 21. Conversion Case — a case where an individual under age 21 was not eligible for MassHealth when admitted to a psychiatric inpatient hospital, but then applied for and received MassHealth while in the psychiatric inpatient hospital. A conversion case is treated as a new admission for purposes of screening and certification by the screening team. Medical Leave of Absence — an inpatient hospital stay of a member who is a resident of a nursing facility for up to 10 consecutive days in a hospital at a Medicare hospital level of care. The day on which a member is transferred from a nursing facility to a hospital for an inpatient stay is the first day of the medical leave of absence from the nursing facility. The day on which a member is transferred from a hospital back to a nursing facility or is otherwise discharged to a noninstitutional setting is not a medical leave-of-absence day. Mental Illness — mental and emotional disorders as defined in the current American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-2 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 Multidisciplinary Treatment Team — a team of mental-health professionals employed by or under contract with a psychiatric inpatient hospital that provides services to members in the facility. The team must include, at a minimum, a board-eligible or board-certified psychiatrist and one of the following: (1) a licensed psychiatric social worker; (2) a licensed registered nurse with specialized psychiatric training or at least one year's experience treating mentally ill individuals; (3) an occupational therapist who is licensed and who has specialized psychiatric training or at least one year's experience treating mentally ill individuals; or (4) a psychologist who has a master's degree in clinical psychology, or a closely related field such as counseling psychology, or who has been certified either by the state in which the psychiatric inpatient hospital is located or by that state's psychological association. Periodic Medical Review (PMR) Team — a team authorized by the MassHealth agency to perform periodic inspections of the care and services provided to MassHealth members in psychiatric inpatient hospitals. Psychiatric Inpatient Hospital — any psychiatric facility or inpatient program in a licensed psychiatric facility that has six beds or more for inpatient use, is certified by the Massachusetts Department of Public Health for participation in Medicare, and primarily treats patients whose principal diagnosis is based on the DSM-IV. For out-of-state psychiatric inpatient hospital providers, certification for participation in MassHealth by the appropriate state agency may be substituted. "Primarily treats" means that, over a six-month period, inpatient care has been provided to a patient population of which 51 percent or more consistently have a principal diagnosis that is psychiatric. Psychiatric Inpatient Hospital Services — psychiatric treatment provided under the direction of a psychiatrist in a psychiatric inpatient hospital. Psychiatric Treatment — treatment that encompasses multidisciplinary assessments and multimodal interventions. Twenty-four-hour skilled nursing care, daily medical care, and a structured treatment milieu are required. Special treatment may include physical and mechanical restraint, isolation, and a locked unit. Screening Team — an independent team that certifies the need for services for members under the age of 21. The team includes, but may not be limited to, a physician, and must (1) be competent in diagnosing and treating mental illness in children; and (2) have knowledge of the member’s condition. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-3 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 Treatment Plan — a documented written plan developed for each member by the hospital multidisciplinary treatment team with the goal of improving the member's condition to the extent that inpatient care is no longer necessary. The treatment plan must include (1) specifications of all services required during the psychiatric inpatient hospital stay; (2) identified discharge plans; (3) when appropriate, indications of the need for DMH Continuing Care Services or for services from other state agencies, or both; and (4) written documentation in the member’s record that the member, his or her legal guardian, and family members are given the opportunity to participate in the development and modification of the treatment plan and the psychiatric treatment itself, and to attend all treatment plan meetings according to the bounds of consent. Working Days — Monday through Friday, except for holidays. 425.403: Eligible Members (A) (1) MassHealth Members. MassHealth covers psychiatric inpatient hospital services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in the 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 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. 425.404: Exclusion of MassHealth Managed Care Members 130 CMR 425.000 does not apply to members participating in a MassHealth managed care plan. Participation in a MassHealth managed care plan is subject to change. Providers are responsible to verify member status on a daily basis. For more information, see 130 CMR 450.117. 425.405: Provider Eligibility Payment for the services described in 130 CMR 425.000 will be made only to psychiatric inpatient hospitals participating in MassHealth on the date of service. (A) In State. To participate in MassHealth, an in-state psychiatric inpatient hospital must (1) be a MassHealth provider; (2) be licensed as a hospital by or be operated by the Massachusetts Department of Mental Health (DMH); (3) be accredited by the Joint Commission on Accreditation of Health Organizations (JCAHO) or be certified by the Massachusetts Department of Public Health; and (4) participate in the Medicare program. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-4 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 (B) Out of State. To participate in MassHealth, an out-of-state psychiatric inpatient hospital must (1) be a MassHealth provider; (2) be approved as a psychiatric inpatient hospital by the governing or licensing agency in its state; (3) be accredited by the JCAHO or be certified by the public health agency in the state in which the psychiatric inpatient hospital is located; (4) participate in its state's medical assistance program; and (5) participate in the Medicare program. 425.406: Admission Criteria for Members under Age 21 (A) A screening team must screen a member under age 21 prior to admission to a psychiatric inpatient hospital or prior to conversion to MassHealth, as defined in 130 CMR 425.402. The screening team will determine and certify whether the admission is medically necessary. (B) To demonstrate the necessity of a psychiatric inpatient hospital admission for a member under age 21, the following conditions must be met: (1) the member must have mental illness, as defined in DMH regulations at 104 CMR 3.01(a); (2) the member must meet one or more of the following criteria: (a) be dangerous to himself or herself; (b) be dangerous to others; or (c) be unable to care for himself or herself; and (3) the moment-to-moment medical observation or clinical management required cannot be provided in a less restrictive setting. (C) A psychiatrist appointed by the MassHealth agency will evaluate disputes between the screening team and the psychiatric inpatient hospital concerning medical necessity and the need for continued hospitalization of a child or adolescent requesting conversion to MassHealth from other third-party insurance coverage. The psychiatrist will interview the child or adolescent and review his or her medical record within three working days of receipt of the psychiatric inpatient hospital's written request and will make an independent determination of medical necessity and the need for continued hospitalization. This determination will constitute a final action of the MassHealth agency. A member or a provider on behalf of a member who disagrees with the determination may file an appeal, as set forth in 130 CMR 425.415. (D) Court-ordered admissions are exempt from the admission criteria stated in 130 CMR 425.406(A) and (B). 425.407: Admission Criteria for Members Aged 21 or Over A member aged 21 or over must meet all of the following conditions of medical necessity: (A) demonstrate symptomatology consistent with DSM-IV (AXES 1-V) diagnosis, which requires and will respond to therapeutic intervention; Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-5 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 (B) be free from any physical conditions that require primary medical care and cleared for treatment in a nonmedical, nonsurgical treatment environment; (C) require 24-hour medical, psychiatric, and nursing services that can appropriately be provided only at an acute level of hospital care; (D) have a psychiatric condition that results in serious dysfunction, such as increased suicidal gestures, assaultiveness, or sudden inability to provide self-care, that endangers the member or others; and (E) present conditions that can reasonably be expected to improve to the extent that psychiatric inpatient hospital services will no longer be needed or further regression of the member’s condition will be prevented. 425.408: Payment Methodology (A) In State. Payments to in-state psychiatric inpatient hospitals for services furnished to MassHealth members will equal the rate established in the signed provider contract with the MassHealth agency. (B) Out of State. Payment to out-of-state psychiatric inpatient hospitals will be the Massachusetts state-wide average per diem rate or administrative day rate established by the MassHealth agency for in-state psychiatric inpatient hospitals. 425.409: Nonreimbursable Services The following services are not reimbursable: (A) drugs and durable medical equipment prescribed for take-home use that are readily available from pharmacies or medical providers; (B) the cost of any treatment or testing of a member or of a specimen from a member who is not an inpatient in the psychiatric inpatient hospital where the treatment or testing occurs; (C) room-and-board services on the day of discharge (unless the day of discharge is also the day of admission). The day of discharge is the day on which a member leaves the hospital for any reason, including death or the start of a leave of absence, whether medical or nonmedical, regardless of the hour of discharge; (D) leave-of-absence days; (E) research or the provision of experimental or unproven procedures; (F) private hospital rooms, except when medically necessary; and (G) services furnished by the emergency room or outpatient department on the day of admission, during the inpatient stay, or on the day of discharge. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-6 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 425.410: Service Limitations (A) For members under age 21, MassHealth covers psychiatric inpatient hospital services until the earlier of the following: (1) the date the member no longer requires the services; or (2) the date the member reaches the age of 21. (B) For members aged 21 through 64, MassHealth covers psychiatric inpatient hospital services up to a maximum of 30 consecutive days per admission. MassHealth covers no more than 60 days of psychiatric inpatient hospital services per year per member. For the purposes of 130 CMR 425.410(B), the MassHealth agency does not count toward these length-of-stay limitations any day for which it has paid only the Medicare Part A coinsurance, deductible, or both. Once a MassHealth member’s Medicare Part A psychiatric inpatient hospital benefits have been exhausted, all other days for which the MassHealth agency makes payment will be counted toward these service limitations. A year is defined as the calendar year in which the psychiatric inpatient hospital services were provided. (C) Members under age 21 must be prescreened by a screening team or be admitted under court order, pursuant to M.G.L. c. 123, §§ 7, 8, 12a, and 12b. 425.411: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services The MassHealth agency pays for all medically necessary psychiatric inpatient hospital services for EPSDT-eligible members in accordance with 130 CMR 450.140 et seq., without regard to service limitations described in 130 CMR 425.000, and with prior authorization. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-6a Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 425.412: Child and Adolescent Needs and Strengths (CANS) Certification The following clinicians are eligible to administer the Child and Adolescent Needs and Strengths (CANS) in psychiatric inpatient hospitals and must be certified every two years, according to the process established by the Executive Office of Health and Human Services (EOHHS): (A) psychiatrists and psychiatric residents; (B) psychiatric nurse mental-health clinical specialists; (C) psychologists who have a specialization in clinical or counseling psychology; (D) social workers who have a master’s degree in social work from an accredited educational institution; and (E) counselors who have a master’s degree in counseling education, counseling psychology, or rehabilitation psychology from an accredited educational institution. 425.413: Child and Adolescent Needs and Strengths (CANS) Data Reporting For each Child and Adolescent Needs and Strengths (CANS) conducted, the hospital must report data collected during the assessment to the MassHealth agency, in the manner and format specified by the MassHealth agency. (130 CMR 425.414 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-6b Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 425.415: Notification and Right of Appeal (A) The MassHealth agency or its agent will send a written notification of approval or denial to the member and to the medical practitioner or facility who submitted the request for psychiatric inpatient hospital services. If authorization for psychiatric inpatient hospital services is denied, the notification will inform the member and the medical practitioner or facility of the reason for the denial, the member's right to appeal, and the appeal process. (B) Following the decision of the MassHealth agency or its agent to deny services in a psychiatric inpatient hospital, a member may appeal by requesting a fair hearing from the MassHealth agency. The request for a fair hearing must be made, in writing, within 30 days after receipt of the notice of the denial. The appeal procedure and fair hearing will be administered and conducted by the Board of Hearings in accordance with the regulations set forth in 130 CMR 610.000. 425.416: Treatment Plan (A) The hospital multidisciplinary treatment team must develop and implement a written treatment plan for each member. For members under age 21, the treatment plan must be developed in conjunction with any case managers the member may have from DMH, DCF, DYS, or DMR. The treatment plan must (1) be developed and reviewed with the fullest possible participation of the member, his or her designated representative or guardian, if any, and individuals in whose care the member will be released after discharge; (2) be based on the findings of an initial assessment; (3) be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral, and developmental aspects of the member's situation and that reflects the need for psychiatric inpatient hospital care; (4) state long- and short-range goals; (5) state, with specific and measurable terms and time frames, treatment objectives that include changes that must occur in order to discharge the patient; (6) prescribe an integrated program of therapies, activities, and experiences designed to meet the treatment objectives; (7) specifically identify the psychiatric symptoms that require psychiatric inpatient hospital care rather than treatment in a less-restrictive setting; (8) be developed and implemented within three calendar days of admission; and (9) include an initial determination of the member's expected length of stay in the facility and the anticipated discharge plan, that is coordinated with outpatient and community providers. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-7 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 (B) The treatment plan for each member must be reviewed, and revised if necessary, by the hospital interdisciplinary review team every seven days from the date of admission to determine that psychiatric services being provided are required on an inpatient basis. If the member's length of stay is less than seven days, the review must be performed at the time of discharge. (C) The treatment plan must be documented in the member's medical record, as set forth in 130 CMR 425.423. 425.417: Conditions for Continuing Care (A) To continue to qualify for psychiatric inpatient hospital services, members must continue to meet the admission criteria described in 130 CMR 425.406 or 425.407, whichever is applicable, or meet one of the conditions in 130 CMR 425.417(B). Members who are under age 21 must also be reviewed by a screening team prior to the 30th day after admission and every 30 days thereafter. (B) Additional Conditions. The following additional conditions qualify a member age 21 or over to continue to receive psychiatric inpatient hospital services, even if the member does not qualify under 130 CMR 425.417(A): (1) the persistence of conditions that necessitated admission, despite therapeutic efforts, or the emergence of additional problems consistent with the admissions criteria in 130 CMR 425.406 or 425.407; (2) a severe reaction to medication; or (3) a need for stabilization of psychiatric conditions, integration of gains, or preparation for transition to outpatient care or a residential setting. 425.418: Discharge Planning (A) The psychiatric inpatient hospital must assign, in writing, the responsibility for all member discharge planning to one department (such as social services or continuing care). (B) Admission data, including but not limited to age and diagnosis, must be screened by discharge-planning staff within 24 hours of admission in accordance with written criteria that identify pertinent patient characteristics and any high-risk diagnoses. Discharge-planning activities must then commence within three working days of admission for every member expected to require post- hospital care or services. Admission data must be noted in the member's record by the discharge-planning department. The written criteria used to screen members must be available to the MassHealth agency. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-8 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 (C) The hospital's discharge-planning staff and interdisciplinary review team must coordinate and document, in writing, a plan for each member who requires post-hospital care. Such plan must be prepared by the hospital's interdisciplinary review team, in conjunction with any primary care provider, DMH, DCF, DYS, or DMR case managers, and must ensure continuity of care with the member's family, school, and community upon discharge. The plan must also specify the services and care required by the member and the frequency, intensity, and duration of such services, including available family and community support. The plan must be updated if the member's condition changes significantly. The hospital must ensure that a clinician certified in accordance with 130 CMR 425.412 completes a CANS during the discharge planning process for members under the age of 21. (D) The hospital must have a written policy that allows discharge-planning staff access to all members and their medical records. If such access is clinically contraindicated, the member's psychiatrist must sign a statement specifying the reason for the contraindication and the hospital must maintain the statement in the member's medical and discharge-planning records. (E) Unless clinically contraindicated, the hospital's discharge-planning staff or interdisciplinary review team must contact the member’s family to involve them in planning the member's discharge. To this end, family members must be informed of the discharge options and community resources available to the member and provided with lists of community resources in the area. (F) Each visit to a member or meeting with the family by a member of the discharge-planning staff must be noted in the member's discharge-planning record. The notation must include the date of the meeting, all discharge options discussed, any problems raised and plans for addressing them, all agreements reached with the member, and additional steps required for the discharge- planning staff to prepare the member for discharge. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-9 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 425.419: Utilization Review (A) The MassHealth agency or its agent will conduct reviews of the necessity and appropriateness of psychiatric inpatient hospital services provided to a member. These reviews may be conducted concurrently with the member's hospital admission or stay or retrospectively following the member's discharge from the hospital. (B) If, as the result of a concurrent review, the MassHealth agency or its agent determines that a member's stay is no longer necessary due to the availability of appropriate resources outside of an institutional setting, the MassHealth agency will not pay for any part of the psychiatric inpatient hospital stay following the 10th day after the date of notice to the hospital and to the member that the stay is no longer necessary. (C) The MassHealth agency or its agent will perform utilization review in accordance with 130 CMR 425.415 and 450.000. (D) If, as the result of a review, the MassHealth agency or its agent denies an admission to a psychiatric inpatient hospital or determines that there was no medical necessity for an admission, a stay, or any part of a stay, the MassHealth agency will not pay for that admission, stay, or part of a stay. (E) If, as the result of a review, the MassHealth agency or its agent determines that any psychiatric inpatient hospital admission, stay, or service provided to a member was subject to a service limitation (see 130 CMR 425.410 and 450.106), the MassHealth agency will not pay for that admission, stay, or service. (F) If a psychiatric inpatient hospital stay or service is reviewed by the MassHealth agency or its agent concurrently with the member's hospital admission or stay and the admission, service, or stay, or any part thereof, is certified at the time of review as medically or administratively necessary and appropriate, the MassHealth agency will treat that certification as binding for payment purposes. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-10 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 425.420: Reimbursable Administrative Days (A) The MassHealth agency pays a psychiatric inpatient hospital for a continued length of stay of up to 30 administrative days, as defined in 130 CMR 425.402. For members under age 21 and members aged 65 and over, the MassHealth agency may pay a hospital for administrative days exceeding the 30-day limit where the hospital can demonstrate, to the satisfaction of the MassHealth agency or its agent, that the hospital has (1) experienced extraordinary difficulty in placing the member, including the specific reasons for such extraordinary difficulty; and (2) exhaustively explored all potential appropriate placements. (B) An administrative day, as defined in 130 CMR 425.402, is reimbursable only if a hospital is making regular efforts to move the member to a less intensive level of care. These efforts must be documented according to the procedures described in 130 CMR 450.205. The regulations covering discharge-planning standards described in 130 CMR 425.418 must be followed, but they do not preclude additional, effective discharge-planning activities. (C) Examples of situations that may require hospital stays at an administrative-day level include, but are not limited to, the following. (1) A member is awaiting transfer to a nursing facility or any other institutional placement, and no appropriate nursing-facility bed is available. (2) A member is awaiting arrangement of residential, social, psychiatric, or medical services by a public or private agency. (3) A member is awaiting results of a report of abuse or neglect made to any public agency charged with the investigation of such reports. (4) A member in the custody of the Department of Children and Families is awaiting foster care when other temporary living arrangements are unavailable or inappropriate. (5) A member cannot be treated or maintained at home because the primary caregiver is absent due to a medical or psychiatric crisis, and a substitute caregiver is not available. 425.421: Nonreimbursable Administrative Days Administrative days are not reimbursable when (A) an appropriate placement is currently available, but the hospital has not transferred or discharged the member because of the hospital's administrative or operational delays; (B) the MassHealth agency or its agent determines that appropriate noninstitutional or institutional placement or services are available within a reasonable distance of the member's noninstitutional (customary) residence and the member, the member's family, or any person legally responsible for the member refuses the placement or services; or (C) the MassHealth agency or its agent determines that appropriate noninstitutional or institutional placement or services are available within a reasonable distance of the member's noninstitutional (customary) residence and advises the hospital of the determination, and the hospital or the physician refuses or neglects to discharge the member. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-11 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 425.422: Periodic Medical Review (A) In compliance with 42 CFR 456.600 through 456.614, the Department of Public Health (by agreement with the MassHealth agency) or the appropriate state survey agency of the psychiatric inpatient hospital's jurisdiction performs periodic medical reviews (PMRs) of the care and services provided to members in psychiatric inpatient hospitals. These inspections take place at least annually, and no psychiatric inpatient hospital may be notified of the inspection time more than 48 hours before the scheduled arrival of the PMR team. (B) The team's review includes (1) personal contact with and observation of each member; and (2) a review of each member's medical record. (C) The team determines whether (1) the services available in the psychiatric inpatient hospital are adequate; (2) it is necessary and desirable for the member to remain in the psychiatric inpatient hospital; (3) it is feasible to meet the member's needs through alternative institutional or noninstitutional services; and (4) each member is receiving active treatment as defined in 42 CFR 441.154. (D) The MassHealth agency sends copies of the PMR report to appropriate state agencies, to the psychiatric inpatient hospital, and to the psychiatric inpatient hospital's utilization review committee. 425.423: Recordkeeping Requirements (A) A record must be established and maintained for each member that is consistent with current professional standards. The record must include the following documents, if applicable: (1) the screening certification from a screening team, as described in 130 CMR 425.406, or appropriate court documentation for court-ordered admissions, pursuant to M.G.L. c. 123, §§ 7, 8, 12a, and 12b; (2) the treatment plan, as described in 130 CMR 425.416; (3) documentation from the hospital interdisciplinary review team supporting the need for continuing care, as described in 130 CMR 425.417; (4) the discharge plan, as described in 130 CMR 425.418; and (5) for members under the age of 21, a copy of the CANS completed during the discharge planning process. (B) No information from the medical record may be released to other providers without a signed authorization form from the member, or his or her legal guardian. (C) Psychiatric inpatient hospitals must adhere to all laws and regulations relating to recordkeeping requirements, including but not limited to the confidentiality regulations in 130 CMR 425.424 and the recordkeeping and disclosure requirements of 130 CMR 450.205. (D) A member's records must be maintained by the psychiatric inpatient hospital for a period of six years following the date of discharge. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-12 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-16 Date 12/26/08 (E) If any litigation, claim, negotiation, audit, or other action involving the records is commenced prior to the expiration of the applicable retention period, all records must be retained until completion of the action and resolution of all issues resulting therefrom, or until the end of the applicable retention period, whichever is later. 425.424: Confidentiality (A) Psychiatric inpatient hospitals must comply with all state and federal laws and regulations relating to confidentiality and privacy. (B) At all times, psychiatric inpatient hospitals must recognize the MassHealth agency's ownership of personal data (as defined in M.G.L. c. 66A, § 1 and regulations at 106 CMR 101.060) and other information deemed confidential by the Commonwealth. (C) If any employee or subcontractor of a psychiatric inpatient hospital is involved with a member's personal data or other confidential information, the psychiatric inpatient hospital must inform the employee or subcontractor of the laws and regulations relating to confidentiality. REGULATORY AUTHORITY 130 CMR 425.000: M.G.L. c. 118E, §§ 7 and 12