Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter EIP-19 January 2012 TO: Early Intervention Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Early Intervention Program Manual (Revised Service Codes and Descriptions) This letter transmits revisions to the service codes and descriptions in the Early Intervention Program Manual. It also reminds early intervention (EI) providers of MassHealth regulations about overpayments, and the need to request prior authorization (PA) for medically necessary services not explicitly covered in the Early Intervention Manual that may be covered as Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. Changes to Service Codes and Descriptions (Subchapter 6) MassHealth has revised service codes and descriptions in the Early Intervention Program Manual to set forth the maximum units that will be paid to early intervention providers for each service code billed for a member who is not eligible for EPSDT services. An EPSDT-eligible member is any member under 21 years old who has MassHealth Standard or Commonhealth coverage. For a member who is eligible for EPSDT, the maximum represents the most units that can be provided without prior authorization (PA), as further described below, and in the Service Codes and Descriptions section of the Early Intervention Program Manual. In addition, MassHealth has increased the maximum allowable units for Service Code H2015 (used to bill for individual child visits, not center based) from eight units per member per day (maximum one visit per member per day) to 16 units per member per day (maximum two visits per member per day). Early intervention providers received a message text in August 2011 that stated that the changes in maximum units for Service Code H2015 took effect for dates of service on or after September 1, 2011. Please note that, unless otherwise specified in the Service Codes and Descriptions section (Subchapter 6), one unit equals 15 minutes. Providers must include the appropriate modifier with each service code when requesting PA or submitting claims. The modifiers are listed in the Subchapter 6 of the Early Intervention Program Manual. Requesting PA for Early Intervention Units in Excess of the Specified Maximum Payable MassHealth regulations at 130 CMR 450.144(A)(2) governing Early and Periodic Screening, Diagnosis and Treatment (EPSDT), permit providers to receive payment for medically necessary services that are not otherwise covered, by requesting PA for such services from MassHealth. As indicated above, this includes all members under 21 years of age who have MassHealth Standard or Commonhealth. MassHealth Transmittal Letter EIP-19 January 2012 Page 2 If an Early intervention provider determines that a member who meets the above EPSDT criteria has a medical need for early intervention services that exceeds the amount payable as described in Subchapter 6 of the Early Intervention Program Manual, the EI provider must request PA before providing the services. MassHealth will review and approve, deny, or modify the request within 21 days of receipt and notify the requesting provider and member of its decision in accordance with 130 CMR 450.303. If MassHealth denies or modifies the request, the notification to the member will include the member’s right to appeal MassHealth’s decision. MassHealth encourages providers to submit all requests for PA electronically via the Provider Online Service Center (POSC). Instructions on how to submit PAs to MassHealth can be viewed on MassHealth’s Web site by clicking on “Information for MassHealth Providers,” then “New Medicaid Management Information Systems (NewMMIS) and the Provider Online Service Center (POSC)” then Need Additional Information or Training?,” then “Get Trained.” Under the “Get Trained” screen, providers can view PA submission instructions by clicking on the specific job aid. Documentation to Submit with the Prior Authorization (PA) Request When requesting PA for EI services that exceed the maximum allowable units, EI providers must include . a copy of the member’s most recent Individual Family Support Plan (IFSP); and . a recent letter from the member’s physician or nurse practitioner. The letter must be dated within at least three months from the date of the PA request, and must clearly describe the medical need for the additional early intervention services requested. Providers must request PA only for the number of units above the maximum allowable that are medically necessary, and include the frequency and duration of the request. For example, if a member’s IFSP requires the member to receive 20 units of H2015 AH three times per week for 24 weeks, the PA request would be for 288 units of H2015 AH for 24 weeks (four units x three times per week x 24 weeks). Providers may submit PA requests on paper by completing the MassHealth Prior Authorization Request form (PA-1) and mailing the form and the above supporting documentation to the address provided on the PA-1 form. The PA-1 form and other forms can be downloaded from the MassHealth Web site. Submitting claims to MassHealth A provider must obtain PA before providing the service that requires it. When submitting a claim for early intervention services that exceeds the maximum allowable units for a service code, enter the service code and modifier for the allowable number of units on one claim line. Enter the same service code and modifier with the number of units that exceed the maximum allowable amount, and for which the provider has obtained PA, on the second claim line. Include the PA number on the claim. MassHealth Transmittal Letter EIP-19 January 2012 Page 3 Overpayments This is a reminder to EI providers that MassHealth periodically conducts audits of services furnished by providers. Such audits may determine the existence and amount of overpayments, which include, but are not limited to . payment made by MassHealth to providers for services that were not payable under MassHealth on the date of service; and . any services paid in excess of the maximum unit limit if the provider did not seek and obtain PA from MassHealth. MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. Questions 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.) Early Intervention Program Manual Pages vi, vii, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Early Intervention Program Manual Page vi — transmitted by Transmittal Letter EIP-15 Page vii — transmitted by Transmittal Letter EIP-13 Pages 6-1 and 6-2 — transmitted by Transmittal Letter EIP-18 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Early Intervention Program Manual Transmittal Letter EIP-19 Date 09/01/11 6. Service Codes and Descriptions Service Codes and Descriptions.................................................................... ............................... 6-1 Appendix A. Directory ................................................................................ ................................ A-1 Appendix B. Enrollment Centers ................................................................................ ...................... B-1 Appendix C. Third-Party-Liability Codes ................................................................................ ........ C-1 Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules ................................................................................ .................................... W-1 Appendix X. Family Assistance Copayments and Deductibles ........................................................ X-1 Appendix Y. EVS Codes/Messages ................................................................................ ................. Y-1 Appendix Z. EPSDT Services Laboratory Codes ............................................................................. Z- 1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vii Early Intervention Program Manual Transmittal Letter EIP-19 Date 09/01/11 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. 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 early intervention programs, those matters are covered in 130 CMR Chapter 440.000, reproduced as Subchapter 4 in the Early Intervention Program Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for 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 6. Service Codes and Descriptions Page 6-1 Early Intervention Program Manual Transmittal Letter EIP-19 Date 09/01/11 601 Service Codes and Descriptions Unless otherwise specified, one unit = 15 minutes. MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 440.000 and 450.000. An early intervention provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Early Intervention Program Manual. For EPSDT-eligible members, the maximum units allowed refers to the maximum number of units payable unless the provider has obtained prior authorization (PA) in accordance with 130 CMR 450.144(A)(2). Providers must include the appropriate modifier with each service code when submitting PA requests or when submitting claims for payment. Service Code-Modifier Service Description H2015 Comprehensive community support services (use for individual child visits, not center-based). (Maximum units allowed per member equal 16 units per member per day, not to exceed two visits per day) H2015-AH services provided by a clinical psychologist H2015-AJ services provided by a clinical social worker H2015-GN services provided by a speech/language therapist H2015-GO services provided by an occupational therapist H2015-GP services provided by a physical therapist H2015-TD services provided by a registered nurse H2015-TE services provided by a licensed practical nurse H2015-HN services provided by a developmental specialist T1015-TL Clinic visit/encounter, all-inclusive (one encounter is defined as one unit) (use for individual child visits, center-based) (maximum units allowed = eight units per day). Clinical justification for the need for services to be provided at an early intervention center rather than a community site must be documented in the member’s Individual Family Service Plan (IFSP) in accordance with DPH operational standards T1023 Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project, or treatment protocol, per encounter (use for EI screening/intake); (use the appropriate modifier(s) below to denote who provided the service); (maximum units allowed per member = eight units per 12-month period) T1023-AH services provided by a clinical psychologist T1023-AJ services provided by a clinical social worker T1023-GN services provided by a speech/language therapist T1023-GO services provided by an occupational therapist T1023-GP services provided by a physical therapist T1023-TD services provided by a registered nurse T1023-TE services provided by a licensed practical nurse T1023-HN services provided by a developmental specialist Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Early Intervention Program Manual Transmittal Letter EIP-19 Date 09/01/11 T1024 Evaluation and treatment by an integrated specialty team contracted to provide coordincare to multiple or severely handicapped children, per encounter (use for EI assessments); (use the appropriate modifier(s) below to denote who provided the service); (maximum units allowed per member = 40 units per 12-month period) T1024-AH services provided by a clinical psychologist T1024-AJ services provided by a clinical social worker T1024-GN services provided by a speech/language therapist T1024-GO services provided by an occupational therapist T1024-GP services provided by a physical therapist T1024-TD services provided by a registered nurse T1024-TE services provided by a licensed practical nurse T1024-HN services provided by a developmental specialist T1027-TL Family training and counseling for child development, per 15 minutes (use for parent-focused group session) (maximum units allowed per member = six units per EI session, one session per week. 96153-U1 Health and behavior intervention, each 15 minutes, face-to-face; group (two or more members) (use for EI-only child group that includes only those children who are enrolled in EI) (maximum units allowed per child = two sessions per week not to exceed a total of 10 units per week). Clinical justification for the need for EI services to be provided in an early intervention-only, child group rather than an EI community child group (96153-U2) must be documented in the member’s Individual Family Service Plan (IFSP) in accordance with DPH operational standards 96153-U2 group (two or more members) (use for EI community child group, for groups of children that include both children enrolled in EI and those not enrolled in EI) (maximum units allowed per member = two EI sessions per week not to exceed a total of 10 units per week)