Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MassHealth

MASSHEALTH
TRANSMITTAL LETTER RHB-17
January 2004
TO:      Rehabilitation Centers Participating in MassHealth FROM:      Beth Waldman, Acting Commissioner
RE:      Rehabilitation Center Manual (Prior Authorization for Certain Therapy Visits)
This letter transmits revisions to the rehabilitation center regulations about therapy services. Effective February 1, 2004, a provider must obtain prior authorization from MassHealth before providing more than eight physical-therapy visits, eight occupational-therapy visits, and 15 speech/language therapy visits (including group therapy and evaluation) to a member within a 12-month period.
The 12-month period for the initial eight or 15 visits begins on the date of the first therapy visit on or after February 1, 2004. For example, if a member’s first therapy visit is February 20, 2004, the 12-month period is February 20, 2004, through February 19, 2005. To simplify accounting of therapy visits, and to allow time for providers to request prior authorization without interrupting an established regimen of therapy to members currently receiving therapy services, MassHealth will begin counting therapy visits for dates of service on or after February 1, 2004. Regardless of the number of therapy visits a member has had before February 1, MassHealth will count the first visit occurring on or after February 1, 2004, as the first visit toward the eight or 15 visits that are allowed without prior authorization. No payment is made for services in excess of eight physical therapy, eight occupational therapy, and 15 speech/language therapy visits to a provider in a 12-month period, unless prior authorization has been obtained from MassHealth.
Examples:
 1.	If a member’s first physical-therapy visit after February 1, 2004, is March 22, 2004, then the 12-month period for physical therapy is March 22, 2004, through March 21, 2005. MassHealth will pay the provider for seven additional physical-therapy visits before March 22, 2005, without prior authorization. To avoid disruption in treatment, providers are encouraged to request prior authorization as soon as they believe that medically necessary therapy will exceed the number of visits allowed without prior authorization.
 2.	If the same member receives occupational therapy in addition to physical therapy, and the first occupational-therapy visit is April 29, 2004, then the 12-month period for occupational therapy is April 29, 2004, through April 28, 2005. MassHealth will pay the provider for seven additional occupational-therapy visits before April 29, 2005, without prior authorization.

MASSHEALTH
TRANSMITTAL LETTER RHB-17 January 2004 Page 2
Requesting Prior Authorization
To request prior authorization, the provider must complete the Request for Prior Authorization form as instructed in MassHealth’s billing instructions, or use the Web-based Automated Prior Authorization System (APAS), which is available at www.masshealth-apas.com.
In addition, the provider must complete a Request and Justification for Therapy Services form and attach it to the prior-authorization request, whether the request is submitted on paper or using APAS. The therapist must sign the Request and Justification for Therapy Services form. If you are using APAS, you can either download this MassHealth form from APAS, or complete it on line and submit it electronically as part of the request.
You can also download the Request and Justification form from the MassHealth Provider Services Web site at www.mahealthweb.com. Click on Publications and Forms. If you prefer, you can also request supplies of this form from this Web site or by submitting a written request to the following address or fax number.
MassHealth
Attn: Forms Distribution P.O. Box 9101 Somerville, MA 02145 Fax: 703-917-4937
When requesting forms, include the name and quantity of the form, your MassHealth provider number, street address (no post office boxes), and contact name and telephone number.
Billing for Services with Prior Authorization
MassHealth will notify the provider and member in writing of its decision on the request for prior authorization. When billing for services, you must enter the prior-authorization number on the claim as indicated below. This prior-authorization number is printed on the approval letter, and if you used APAS to request prior authorization, it is also listed on APAS. When billing for authorized services:
 •	Enter the six-character prior-authorization number in Item 4 of claim form no. 9 or its electronic equivalent. If you are billing in the 837P format, refer to the Detail Data section of the MassHealth 837P Companion Guide for correct placement of this number on the claim.
 •	Do not include on the same claim form (or electronic equivalent) any therapy services that are part of the original eight or 15 that do not require prior authorization.
Maintenance Program
The attached revisions to the rehabilitation center regulations also clarify that MassHealth does not pay for performance of a maintenance program. A maintenance program is defined as repetitive activities intended to maintain function that can be performed safely and effectively without the skilled assistance of a qualified therapist. MassHealth pays for designing a maintenance program and instructing the member, member’s family, or other persons in its use as part of a regular treatment visit, not as a separate service.

MASSHEALTH
TRANSMITTAL LETTER RHB-17 January 2004 Page 3
Effective Date
These regulations are effective February 1, 2004.
Questions
If you have any questions about the information in this letter, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Rehabilitation Center Manual
Pages 6-1 and 6-2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Rehabilitation Center Manual
Pages 6-1 and 6-2 — transmitted by Transmittal Letter RHB-15

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
REHABILITATION CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-1	

	TRANSMITTAL LETTER
RHB-17	DATE
02/01/04	
430.601:  Introduction
All rehabilitation centers participating in MassHealth must comply with the regulations of MassHealth governing MassHealth, including, but not limited to 130 CMR 430.000 and 450.000.
(A)	Definitions.
 (1)	Eligible Provider of Rehabilitation Center Services – a freestanding center providing rehabilitation services that is licensed by the Massachusetts Department of Public Health and accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).
 (2)	Group Session – therapeutic services directed toward more than one patient in a single visit, using group participation as a treatment technique.
 (3)	Maintenance Program – repetitive activities intended to maintain function that can be performed safely and effectively without the skilled assistance of a qualified therapist.
 (4)	Physician’s Comprehensive Rehabilitation Evaluation – a cardiopulmonary, neuromuscular, orthopedic, and functional assessment performed at a rehabilitation center by a physician.
 (5)	Rehabilitation – the process of providing, in a coordinated manner, those comprehensive services deemed appropriate to the needs of a physically disabled individual, in a program designed to achieve objectives of improved health and welfare with the realization of his or her maximum physical, social, psychological, and vocational potential.
 (6)	Therapist’s Evaluation – an evaluation performed by a physical therapist, an occupational therapist, or a speech therapist at a rehabilitation center.
 (7)	Therapy Visit – a personal contact with a member by a licensed physical therapist, occupational therapist, or speech and language therapist for the purpose of providing a covered service.
(B)	Eligible Members.
(1)	(a) MassHealth Members. MassHealth covers rehabilitation services only when
provided to eligible MassHealth members, subject to the restrictions and limitations
described in MassHealth’s 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.
(b) 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.
(2)	For information on verifying member eligibility and coverage type, see 130 CMR 450.107.
(C)	General Requirements.
 (1)	The rate of payment for a service is the lower of either the provider’s usual fee to patients other than MassHealth members or the amount in the applicable Division of Health Care Finance and Policy fee schedule.
 (2)	The rates of payment do not apply to the following services:

 (a)	medical services except as required for a comprehensive rehabilitation evaluation;
 (b)	psychology services; and
 (c)	audiology services.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
REHABILITATION CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-2	

	TRANSMITTAL LETTER
RHB-17	DATE
02/01/04	
(D)	Prior Authorization.
(1)	MassHealth requires rehabilitation centers to obtain prior authorization for the following
services to eligible MassHealth members. (See also 130 CMR 450.303.)
 (a)	more than eight occupational-therapy visits or eight physical-therapy visits, including an evaluation and group-therapy visits, for a member in a 12-month period; and
 (b)	more than 15 speech/language therapy visits, including an evaluation and group-therapy visits, for a member in a 12-month period.
(2)	The rehabilitation center must submit all prior-authorization requests in accordance with
the instructions in Subchapter 5 of the Rehabilitation Center Manual. Prior authorization
determines only the medical necessity of the authorized service, and does not establish or
waive any other prerequisites for payment, such as member eligibility or resort to health
insurance payment.
(E)	Noncovered Services. MassHealth does not pay for performance of a maintenance program.
MassHealth pays for designing a maintenance program and instructing the member, member’s
family, or other persons in its use as part of a regular treatment visit, not as a separate service.