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 ALL-171 October 2009 TO: All Providers Participating in MassHealth FROM: Terence G. Dougherty, Interim Medicaid Director RE: All Provider Manuals (Revised Regulations and Updated EPSDT Information) These regulatory changes replace the term “legend drug” with “prescription drug,” replace the term “nonlegend drug” with “over-the-counter drug,” clarify the EPSDT provisions by establishing distinct Dental and Medical Protocol and Periodicity Schedules and responsibilities, clarify procedures for requesting prior authorization for certain EPSDT behavioral health services, list the revised menu of standardized behavioral health screening tools for children under 21, and further clarify and update the well-child visit screening requirements. This letter also transmits a revised Appendix W for all MassHealth provider manuals. This appendix contains the medical protocol and periodicity schedule for the Early and Periodic Screening, Diagnosis and Treatment Program. MassHealth has updated the appendix to reflect current standards of care. These regulations and revised Appendix W are effective November 1, 2009. 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.) All Provider Manuals Pages i, 1-3, 1-4, 1-13, 1-14, 1-25 through 1-32, and W-1 through W-8 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Pages i, 1-25 through 1-32 and W-1 through W-6 — transmitted by Transmittal Letter ALL-155 Pages 1-3 and 1-4 — transmitted by Transmittal Letter ALL-149 Pages 1-13 and 1-14 — transmitted by Transmittal Letter ALL-163 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page i All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 1. Introduction 450.101: Definitions......................................................................................................... 1-1 450.102: Purpose of 130 CMR 400.000 through 499.000................................................ 1-5 450.103: Promulgation of Regulations............................................................................. 1-5 (130 CMR 450.104 Reserved) 450.105: Coverage Types................................................................................................. 1-6 450.106: Emergency Aid to the Elderly, Disabled and Children Program....................... 1-14 450.107: Eligible Members and the MassHealth Card..................................................... 1-15 450.108: Selective Contracting......................................................................................... 1-16 450.109: Out-of-State Services......................................................................................... 1-16 (130 CMR 450.110 and 450.111 Reserved) 450.112: Advance Directives............................................................................................ 1-16 (130 CMR 450.113 through 450.116 Reserved) 450.117: Managed Care Participation............................................................................... 1-18 450.118: Primary Care Clinician (PCC) Plan................................................................... 1-18 (130 CMR 450.119 through 450.123 Reserved) 450.124: Behavioral Health Services................................................................................ 1-23 (130 CMR 450.125 through 450.129 Reserved) 450.130: Copayments Required by MassHealth............................................................... 1-24 (130 CMR 450.131 through 450.139 Reserved) 450.140: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction........................................................................................................ 1-26 450.141: EPSDT Services: Definitions............................................................................ 1-26 450.142: EPSDT Services: Medical Protocol and Periodicity Schedule......................... 1-27 450.143: EPSDT Services: Description of EPSDT Visits............................................... 1-27 450.144: EPSDT Services: Diagnosis and Treatment...................................................... 1-28 450.145: EPSDT Services: Claims for Visits.................................................................. 1-29 450.146: EPSDT Services: Claims for Laboratory Services, Audiometric Hearing Tests, Vision Tests, and Behavioral Health Screening (Physician, Independent Nurse Practitioner, Independent Nurse Midwife, and Community Health Center Only) ........................................................................................................................... 1-30 (130 CMR 450.147 Reserved) 450.148: EPSDT Services: Payment for Transportation.................................................. 1-30 450.149: EPSDT Services: Recordkeeping Requirements.............................................. 1-30 450.150: Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) for Certain MassHealth Members...................................................................... 1-30 (130 CMR 450.151 through 450.199 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-3 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 MassHealth Agency — the Executive Office of Health and Human Services in accordance with the provisions of M.G.L. c. 118E. MassHealth Enrollment Center (MEC) — a regional office of MassHealth that determines MassHealth eligibility of individuals and families who do not receive cash assistance (TAFDC, EAEDC, SSI). MassHealth Managed Care Provider — a Primary Care Clinician participating in the Primary Care Clinician Plan or a managed care organization that has contracted with the MassHealth agency to provide and coordinate primary care and certain other medical services to certain MassHealth members. Medicaid — see “MassHealth.” Medical Services — medical or related care, including goods and services provided to members, the cost of which is paid or payable by the MassHealth agency. Medicare — a federally administered health insurance program for persons eligible under the Health Insurance for the Aged Act, Title XVIII of the Social Security Act (42 U.S.C. 1395-1395pp). Member — a person determined by the MassHealth agency to be eligible for MassHealth. Multiple-Source Drug — a drug marketed or sold by two or more manufacturers or labelers, or a drug marketed or sold by the same manufacturer or labeler under two or more different names. Overpayment — a payment made by the MassHealth agency to or for the use of a provider to which the provider was not entitled under applicable federal and state laws and regulations. Over-the-Counter-Drug — any drug for which no prescription is required by federal or state law. These drugs are sometimes referred to as nonlegend drugs. Party in Interest — a person with an ownership or control interest. Peer Review — an evaluation of the quality, necessity, and appropriateness of medical services provided by a provider, to determine compliance with professionally recognized standards of health care or compliance with laws, rules, and regulations under which MassHealth is administered. Prescription Drug — any drug for which a prescription is required by applicable federal or state law or regulation, other than MassHealth regulations. These drugs are sometimes referred to as legend drugs. Primary Care — the provision of coordinated, comprehensive medical services, on both a first-contact and a continuous basis, to members enrolled in managed care. Services include an initial medical history intake, medical diagnosis and treatment, communication of information about illness prevention, health maintenance, and referral services. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-4 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 Primary Care Clinician (PCC) Plan — a managed care option administered by the MassHealth agency through which enrolled members receive primary care and certain other medical services. Provider — an individual, group, facility, agency, institution, organization, or business that furnishes medical services and participates in MassHealth under a provider contract with the MassHealth agency. For purposes of applying 130 CMR 450.235 through 450.240, the term "provider" includes formerly participating providers. Provider Contract (also referred to as “Provider Agreement”) — a contract between the MassHealth agency and a contractor for medical services. Provider Type — a provider classification specifying and limiting the kinds of medical services for which the provider may be paid under MassHealth. Provider under Common Ownership — two or more providers in which a person or corporation has or had, at any time, an ownership or control interest, whether concurrently, sequentially, or otherwise. See 130 CMR 450.221(A)(9)(a), (b), (c), or (f). Sanction — an administrative penalty imposed by the MassHealth agency pursuant to M.G.L. c. 118E, §37 against a provider found to have violated MassHealth laws, regulations, or contract requirements. Sanctions include, but are not limited to, administrative fines, suspension, and termination from participation in MassHealth. Statutory Prerequisite — any license, certificate, permit, or other requirement imposed by state or federal law or regulation as a precondition to the practice of any profession or to the operation of any business or institution in or by which medical services are provided. Statutory prerequisites include, but are not limited to, licenses required by the Massachusetts Department of Public Health or the Massachusetts Department of Mental Health, licenses and certificates issued by the Massachusetts boards of registration, and certificates required by the Massachusetts Department of Public Safety. Third Party — any individual, entity, or program other than MassHealth that is or may be liable to pay all or part of the costs for medical services. Transitional Aid to Families with Dependent Children (TAFDC) — a federally funded program administered by the Massachusetts Department of Transitional Assistance that provides cash assistance to certain low-income families. Urgent Care — medical services that are not primary care, and are needed to treat a medical condition that is not an emergency medical condition. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-13 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 (aa) prosthetic services; (bb) rehabilitation services; (cc) renal dialysis services; (dd) speech and hearing services; (ee) therapy services: physical, occupational, and speech/language; (ff) vision care; and (gg) X-ray/radiology services. (4) Managed Care Participation. (a) MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(E) must enroll with a Primary Care Clinician or a MassHealth-contracted managed care organization (MCO) (see 130 CMR 450.117). (b) MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(F) must enroll with a Primary Care Clinician (see 130 CMR 450.118.) (5) Managed Care Organizations. For MassHealth Family Assistance members who are enrolled in a MassHealth MCO, the following rules apply. (a) The MassHealth agency does not pay a provider other than the MCO for any services that are covered by the MassHealth agency’s contract with the MCO, except for family planning services that were not provided or arranged for by the MCO. It is the responsibility of the provider to verify the scope of services covered by the MassHealth agency’s contract with the MCO. (b) The MassHealth agency pays providers other than the MCO for those services listed in 130 CMR 450.105(H)(3) that are not covered by the MassHealth agency’s contract with the MCO. Such payment is subject to all conditions and restrictions of MassHealth, including all applicable prerequisites for payment. (6) Behavioral Health Services. (a) MassHealth Family Assistance members enrolled in the PCC Plan receive behavioral health services only through the MassHealth agency’s behavioral health contractor. (See 130 CMR 450.124 et seq.) (b) MassHealth Family Assistance members enrolled in an MCO receive behavioral health services only through the MCO. (See 130 CMR 450.117 et seq.) (c) MassHealth Family Assistance members who are not receiving premium assistance, and have not enrolled in an MCO or been enrolled with the MassHealth agency’s behavioral health contractor may receive behavioral health services from any participating MassHealth provider of such services. (I) MassHealth Essential. MassHealth Essential members receive services through either the purchase of medical benefits or premium assistance. (1) Covered Services. The following services are covered for MassHealth Essential members (see 130 CMR 505.007 and 519.013): (a) abortion services; (b) acute inpatient hospital services; (c) ambulance services (emergency only); (d) ambulatory surgery services; (e) behavioral health (mental health and substance abuse) services; (f) community health center services; (g) dental services; (h) durable medical equipment and supplies; (i) family planning services; Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-14 All Provider Manuals Transmittal Letter ALL-171 Date 011/01/09 (j) laboratory services; (k) nurse practitioner services; (l) outpatient hospital services; (m) oxygen and respiratory therapy equipment; (n) pharmacy services; (o) physician services; (p) podiatrist services; (q) prosthetic services; (r) rehabilitation services (except in inpatient hospital settings); (s) renal dialysis services; (t) speech and hearing services; (u) therapy services: physical, occupational, and speech/language; (v) vision care services provided by a licensed doctor of optometry, including eye exams and supplementary testing services, but not including the provision or dispensing of ophthalmic materials such as eyeglasses, contact lenses, or other visual aids; and (w) X-ray/radiology services. (2) Managed Care Member Participation. MassHealth Essential members for whom eligibility is determined under 130 CMR 505.007 must enroll with a Primary Care Clinician as described in 130 CMR 450.117(B)(1). These members are eligible to receive services listed in 130 CMR 450.105(I)(1) only after enrolling with a Primary Care Clinician in accordance with 130 CMR 508.002(I)(2), except as described in 130 CMR 505.007(E). (3) Behavioral Health Services. MassHealth Essential members enrolled in the PCC Plan receive behavioral health services only through the MassHealth agency’s behavioral health contractor. (See 130 CMR 450.124 et seq.) (4) Premium Assistance. For adults who meet the eligibility requirements for MassHealth Essential but have health insurance, the MassHealth agency pays part, or all, of the member’s health insurance premium. The amount of the payment for premium assistance is based on the MassHealth agency’s determination of cost effectiveness. The MassHealth agency does not pay for any other benefits for these members, except as described in 130 CMR 505.007(E). Premium assistance members are excluded from participation in managed care in accordance with 130 CMR 508.004(B). 450.106: Emergency Aid to the Elderly, Disabled and Children Program (A) Covered Services. The following services are covered for EAEDC recipients: (1) physician services specified in 130 CMR 433.000; (2) community health center services specified in 130 CMR 405.000; (3) prescription drugs (those drugs that require a prescription under federal or state law) specified in 130 CMR 406.000; (4) insulins (the only over-the-counter drugs that are covered) and diabeticsupplies; (5) infusion (intravenous) therapy, including chemotherapy, pain management, antibiotics, chelation, and cardiac management; (6) oxygen and respiratory therapy services specified in 130 CMR 427.000; (7) substance abuse treatment services as specified in 130 CMR 418.000 if provided in public detoxification and outpatient substance abuse treatment centers; and (8) diagnostics and testing (such as laboratory, radiology, magnetic resonance imaging, or psychological testing) necessary for the determination or redetermination of eligibility for the EAEDC Program, upon referral from a physician or a community health center. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-25 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 (h) independent foster care adolescents who were in the care and custody of the Department of Social Services on their 18th birthday and who are eligible for MassHealth Standard until they reach age 21. (2) Members who have accumulated copayment charges totaling the calendar-year maximum of $200 on pharmacy services do not have to pay further MassHealth copayments on pharmacy services during the calendar year in which the member reached the MassHealth copayment maximum for pharmacy services. (3) Members who have accumulated copayment charges totaling the calendar-year maximum of $36 on non-pharmacy services do not have to pay further MassHealth copayments on nonpharmacy services during the calendar year in which the member reached the MassHealth copayment maximum for nonpharmacy services. (4) Members who have other comprehensive medical insurance, including Medicare, do not have to pay MassHealth copayments on nonpharmacy services. (5) Members who are inpatients in a hospital do not have to pay a separate copayment for pharmacy services provided as part of the hospital stay. (E) Excluded Services. The following services are excluded from the copayment requirement described in 130 CMR 450.130(B): (1) family-planning services and supplies such as oral contraceptives, contraceptive devices such as diaphragms and condoms, and contraceptive jellies, creams, foams, and suppositories; (2) nonpharmacy behavioral health services; and (3) emergency services. (F) Notice to Members about Exclusions from the Copayment Requirement. Pharmacies and hospitals must post a notice about MassHealth copayments in areas where copayments are collected. The notice must be visible to the public and easily readable and must specify the exclusions from the copayment requirement listed in 130 CMR 450.130(D) and (E), and instruct members to inform providers if members believe they are excluded from the copayment requirement. (G) Collecting Copayments. (1) A member must pay the copayment described in 130 CMR 450.130(B) at the time the service is provided unless the member is exempt under 130 CMR 450.130(D) or (E), claims that he or she is exempt from the copayment, or claims that he or she is unable to make the copayment at the time the service is provided. The member's inability to make the copayment at the time service is provided does not eliminate the member's liability for the copayment, and providers may bill the member for the copayment amount. (2) The MassHealth agency will deduct the amount of the copayment from the amount paid to the provider, whether or not the provider collects the copayment from the member, unless the member or service is exempt according to 130 CMR 450.130(D) or (E). Providers should not deduct the copayment amount from the amount claimed. Providers may not refuse services to any members who are unable to pay the copayment at the time service is provided. (H) Receipt. The provider must give the member a receipt identifying the provider, service, date of service, member, and amount paid. (I) Recordkeeping. Providers must keep all records necessary to determine if a copayment was collected from a member for a service on a specific date. (130 CMR 450.131 through 450.139 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-26 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 450.140: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction (A) Legal Basis. (1) In accordance with federal law at 42 U.S.C. 1396d(a)(4)(b) and (r) and 42 CFR 441.50, and notwithstanding any limitations implied or expressed elsewhere in MassHealth regulations or other publications, the MassHealth agency has established a program of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for MassHealth Standard and MassHealth CommonHealth members under age 21 years, including those who are parents. (2) Any MassHealth provider may deliver EPSDT services. However, in delivering well-child care, providers must follow the EPSDT Medical Protocol and Periodicity Schedule. (3)EPSDT screening services include among other things, health, vision, dental, hearing, behavioral health, developmental and immunization status screening services. (4) The regulations governing the EPSDT program are set forth in 130 CMR 450.140 through 450.149. (B) Program Objectives. The objectives of the EPSDT program are (1) to provide comprehensive and continuous health care designed to prevent illness and disability; (2) to foster early detection and prompt treatment of health problems before they become chronic or cause irreversible damage; (3) to create an awareness of the availability and value of preventive well-child care services; and (4) to create an awareness of the services available under the EPSDT program, and where and how to obtain those services. 450.141: EPSDT Services: Definitions Dental Care — dental services customarily furnished by or through dental providers as defined in 130 CMR 420.000, to the extent the furnishing of those services is authorized by the MassHealth agency. EPSDT Medical Protocol and Periodicity Schedule (the Medical Schedule) — a schedule (see Appendix W of all MassHealth provider manuals) developed and periodically updated by the MassHealth agency in consultation with recognized medical and dental organizations involved in child health care. The Medical Schedule consists of screening procedures arranged according to the intervals or age levels at which each procedure is to be provided. EPSDT Dental Protocol and Periodicity Schedule (the Dental Schedule) — a schedule (see Appendix W) developed and periodically updated by the MassHealth agency in consultation with recognized medical and dental organizations involved in child health care. The Dental Schedule consists of screening and treatment procedures arranged according to the intervals or age levels at which each procedure is to be provided. Interperiodic Visit — the provision of screening procedures or treatment services at an age other than those indicated on the Medical or the Dental Schedule. Interperiodic visits may be: Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-27 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 (1) screenings that are medically necessary to determine the existence of a suspected illness or condition, or a change in or complication of a preexisting condition; (2) the provision of the full-range of EPSDT screening or treatment services delivered at an age other than one listed on the Medical or Dental Schedule to update the member's care according to the Medical or Dental Schedule; or (3) additional screening or treatment services provided to a member whose care is already up-to-date according to the Medical or Dental Schedule. Periodic Visit — the provision of screening procedures appropriate to the member's age and medical history, as prescribed by the Medical Schedule or the Dental Schedule. Primary Care — health care services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, independent nurse practitioner, or independent nurse midwife, to the extent the furnishing of those services is legally authorized in the Commonwealth. Primary care does not include emergency or poststabilization services provided in a hospital or other setting. Primary Care Provider — a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, independent nurse practitioner or independent nurse midwife. 450.142: EPSDT Services: Medical Protocol and Periodicity Schedule and Dental Protocol and Periodicity Schedule (A) Providers of Periodic and Interperiodic Visits. (1) Primary care providers must offer to conduct periodic and medically necessary interperiodic visits to screen all members under age 21 (except members enrolled in MassHealth Limited) in accordance with the Medical Schedule, and must provide or refer such members to assessment, diagnosis, and treatment services. (2) Hospitals and community health centers that provide primary care services must offer to conduct periodic and medically necessary interperiodic visits to screen all members under age 21 (except members enrolled in MassHealth Limited) in accordance with the Medical Schedule, and must provide or refer such members to assessment, diagnosis, and treatment services. (3) The health assessments described in the Medical Schedule are payable when provided by a physician, independent nurse practitioner, independent nurse midwife, hospital, community health center, or nurse practitioner, nurse midwife, or physician assistant under a physician's supervision. (B) Providers of Dental Services. (1) Dental care providers must offer to provide services listed in Appendix W to all members under age 21 (except members enrolled in MassHealth Limited) in accordance with the Dental Schedule, and must provide or refer such members to assessment, diagnosis, and treatment services. (2) The dental services described in the Dental Schedule are payable when provided by dental providers as described in 130 CMR 420.000. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-28 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 (C) Explanation of Procedures. (1) The Medical Schedule outlines the procedures for comprehensive preventive care that help to identify members who may require further diagnosis of suspected or actual health problems, treatment of these problems, or both. (2) The Medical Schedule explains procedures that must be documented in the medical record. (3) The Dental Schedule is a tool to help dental providers identify members with suspected or actual dental problems that may require additional investigation, diagnosis, or treatment. 450.143: EPSDT Services: Description of Medical Protocol and Periodicity Schedule Visits (EPSDT Visits) (A) Initial EPSDT Visit. (1) An initial EPSDT visit must be provided for every (a) new member; (b) member previously seen only for sick care; and (c) newborn previously seen only in the hospital. (2) An initial EPSDT visit includes the recording of (a) family, medical, behavioral health, developmental, and immunization history; (b) a review of all systems; (c) a comprehensive physical examination; and (d) all exams, assessments, screening, and laboratory work indicated on the Medical Schedule as appropriate for the member's age. (B) EPSDT Periodic Visit. (1) An EPSDT periodic visit consists of all exams, assessments, screenings, and laboratory work indicated on the Medical Schedule as appropriate for the member's age. (2) A provider may claim payment for an EPSDT periodic visit only when all the screening procedures on the Medical Schedule that correspond to the member's age have been delivered to the member. (a) While the screening procedures are based upon a presumption of regular contact with health-care providers, many members will need additional screening procedures to bring them up to date. (b) It is the provider's responsibility to provide those additional screening procedures necessary to bring the member up to date with his or her preventive health care according to the Medical Schedule. (3) If the provider is unequipped to perform a test (for example, if he or she does not have an audiometer and an audiometric test is required), the provider must make a screening referral to another provider. However, in every case, for the referring provider to claim payment for an EPSDT periodic visit (a) all required screening procedures must be performed; and (b) the referring provider must receive and document all results in the member’s medical record. (C) EPSDT Interperiodic Visit. An EPSDT interperiodic visit is any visit not indicated on the Medical Schedule. Such visits may be either (1) preventive health-care visits provided at an age or age interval not indicated on the Medical Schedule; or Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-29 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 (2) a screening that is medically necessary to determine the existence of a suspected illness or condition, or a change in or complication of a preexisting condition. 450.144: EPSDT Services: Diagnosis and Treatment (A) (1) EPSDT diagnosis and treatment services consist of all medically necessary services listed in 1905(a) of the Social Security Act (42 U.S.C. 1396d(a) and (r)) that are (a) needed to correct or ameliorate physical or mental illnesses and conditions discovered by a screening, whether or not such services are covered under the State Plan; and (b) payable for MassHealth Standard and MassHealth CommonHealth members under age 21 years, if the service is determined by the MassHealth agency to be medically necessary. (2) To receive payment for any service described in 130 CMR 450.144(A)(1) that is not specifically included as a covered service under any MassHealth regulation, service code list, or contract, the requester must submit a request for prior authorization in accordance with 130 CMR 450.303. This request must include, without limitation, a letter and supporting documentation from a MassHealth-enrolled physician, nurse practitioner, or nurse midwife documenting the medical need for the requested service. If the MassHealth agency approves such a request for service for which there is no established payment rate, the MassHealth agency will establish the appropriate payment rate for such service on an individual-consideration basis in accordance with 130 CMR 450.271. If the request is for a member who is enrolled in a MassHealth-contracted managed care organization, as defined in 130 CMR 508.000, the requestor must submit the request to the managed care organization according to the managed care organization’s prior-authorization process. If the request is for a behavioral health service for a member who is enrolled with MassHealth’s behavioral health contractor, as defined in 130 CMR 508.000, the requestor must submit the request to the behavioral health contractor according to the behavioral health contractor’s prior authorization process. (B) For any condition that requires further assessment, diagnosis or treatment after the periodic or interperiodic visit, the provider must inform the member how and where to obtain further assessment, diagnosis, or treatment, and must either (1) request that the member return for another appointment as soon as possible; or (2) make a referral to another provider who can provide the appropriate assessment, diagnosis, or treatment as soon as the referring provider determines that a referral is needed. (C) When making a referral to another provider, the referring provider must give the name and address of an appropriate provider to the member or to the member's parent or guardian. (D) The referring provider must obtain a report of the results of assessment, diagnosis, and treatment from the provider of the referred service and document this information in the member's medical record. 450.145: EPSDT Services: Claims for Visits (A) Initial EPSDT Visit. A provider may bill for only one initial EPSDT visit per member. (B) Periodic Visits. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-30 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 (1) For each member from birth through two years of age, a provider may bill for only one periodic visit per age level listed in the Medical Schedule. (2) For each member aged two years through 20 years, a provider may bill for only one periodic visit every year. (C) Interperiodic Visits. There is no limit on the number of medically necessary interperiodic visits that may be billed. Only interperiodic visits, at which the full range of EPSDT screening services are delivered, are payable as EPSDT periodic visits, subject to the limitations in 130 CMR 450.145(B). Any other interperiodic visit is payable according to the visit service codes and descriptions in Subchapter 6 of the screening provider's MassHealth provider manual. (D) Newborn Visits. (Physician, Independent Nurse Practitioner, Independent Nurse Midwife and Community Health Center Providers Only) (1) To be paid for an EPSDT periodic visit of a newborn, the provider must have visited the newborn at least twice before the newborn leaves the hospital. (a) The first visit, for an initial history and physical examination, is payable as newborn care and not as an EPSDT periodic visit. (b) The second visit, for a discharge history, physical examination, and all other screens required for the newborn, is payable as an EPSDT periodic visit. (2) Additional hospital visits for ill newborns are payable according to the service codes and descriptions for hospital visits. (3) The newborn EPSDT periodic visit may occur at the provider's office if the infant's length of stay in the hospital is not long enough for the provider to visit the infant twice before the infant is discharged from the hospital. (E) Reporting Requirement. To claim payment for an EPSDT initial, periodic, or interperiodic visit, a provider must submit a completed claim according to the billing instructions in Subchapter 5 of the applicable MassHealth provider manual. 450.146: EPSDT Services: Claims for Laboratory Services, Audiometric Hearing Tests, Vision Tests, and Behavioral Health Screening (Physician, Independent Nurse Practitioner, Indpendent Nurse Midwife, and Community Health Center Providers Only) (A) Laboratory Services. The laboratory services that are listed in Appendix Z of all MassHealth provider manuals and included in the Schedule are payable, in addition to the initial, periodic, or interperiodic visit, when they are performed and interpreted in the office of the provider who performed the initial, periodic, or interperiodic visit. (B) Audiometric Hearing and Vision Tests. Payment for the audiometric hearing tests and the bilateral quantitative screening test of visual acuity that are listed in Appendix Z of all MassHealth provider manuals and included in the Medical Schedule, is not included in the fee for an initial, periodic, or interperiodic visit. Payment for these tests may be claimed separately. (C) Behavioral Health Screening. Payment for the administration and scoring of one of the standardized behavioral health screening tools that is listed in Appendix Z of all MassHealth provider manuals and set forth in the Medical Schedule is not included in the fee for an initial, periodic, or interperiodic visit. (130 CMR 450.147 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-31 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 450.148: EPSDT Services: Payment for Transportation Transportation may be available to members accessing EPSDT services. Providers must ask members if they need transportation assistance, and refer those members who do to MassHealth Customer Service for additional information about transportation. 450.149: EPSDT Services: Recordkeeping Requirements (A) Medical Records. (1) A provider must create and maintain a record for every member receiving EPSDT services, in accordance with MassHealth regulations governing medical records at 130 CMR 450.205. (2) In addition, the medical record for each member receiving EPSDT services must contain documentation of the screening procedures listed in Appendix W as well as the following: (a) the results of all laboratory tests; (b) the name of each referral provider; and (c) the results of any component of the Medical Schedule that was delivered by another provider. (B) Determination of Compliance with Medical Standards. The MassHealth agency may review the medical records of members receiving EPSDT services to determine the necessity and quality of the medical services provided. Any such determinations will be made in accordance with 130 CMR 450.206. 450.150: Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) Services for Certain MassHealth Members (A) MassHealth has established a program of preventive pediatric health-care screening and diagnosis services for MassHealth members under the age of 21 years who are enrolled in MassHealth Basic, MassHealth Essential, MassHealth Prenatal, and MassHealth Family Assistance. MassHealth Standard and MassHealth CommonHealth members are entitled to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services pursuant to 130 CMR 450.140. (B) Any qualified MassHealth provider may deliver preventive Pediatric health-care screening and diagnosis services. (1) In delivering preventive pediatric health-care screening and diagnosis services, providers must (a) follow the procedures listed in the Medical Schedule; and (b) comply with the regulations at 130 CMR 450.140 through 450.150. (2) Preventive pediatric health-care screening and diagnosis services include health, vision, dental, hearing, and immunization status screening services. (3) To interpret the applicable EPSDT regulations for children enrolled in MassHealth Basic, MassHealth Essential, MassHealth Prenatal, and MassHealth Family Assistance, providers should substitute the term, preventive pediatric health-care diagnosis and treatment services, for the term, Early and Periodic Screening, Diagnosis and Treatment Services, wherever it appears. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-32 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 (C) Providers delivering preventive pediatric health-care screening and diagnosis services should provide members with, or refer members for, additional diagnosis and treatment services according to 130 CMR 450.105. (130 CMR 450.151 through 450.199 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules Page W-1 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Medical Protocol and Periodicity Schedule (the Medical Schedule) and EPSDT Dental Protocol and Periodicity Schedule (the Dental Schedule) The Medical Schedule The EPSDT Medical Protocol and Periodicity Schedule (the Medical Schedule) consists of screening procedures arranged according to the intervals or age levels at which each procedure is to be provided. See 130 CMR 450.140 through 450.150 for more information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) services. Pediatric Preventive Health-Care Visits – Pediatric preventive health-care visits must contain the components explained in the descriptions in the EPSDT Medical Protocol and Periodicity Schedule; and occur at the following ages, at a minimum: one to two weeks, one month, two months, four months, six months, nine months, 12 months, 15 months, 18 months, two years, and then every year until the member’s 21st birthday. Initial or Interval Health History Initial – An initial history must be taken at the first EPSDT or PPHSD visit delivered to a member by a provider. The initial health history includes the family health history and baseline data on the member, including but not limited to (a) growth and developmental history; (b) immunization history; (c) medications and known reactions to medications and allergies; and (d) pertinent information about previous illnesses and hospitalizations, risk-taking behaviors, such as drug, alcohol, and tobacco use, sexual activity, and other medical, psychosocial, and behavioral health concerns. Interval – An interval history must be taken at each periodic EPSDT or PPHSD visit. The interval history includes an update of the member’s medical history, including but not limited to: (a) a review of all systems and any illnesses, diseases, medications, or medical problems experienced by the member since the last visit; and (b) an updated assessment of lifestyle, risk behavior, sexual activity, psychosocial, and behavioral health concerns. Comprehensive Physical Examination – Each EPSDT or PPHSD visit must include an unclothed physical examination, including assessment of growth parameters using height and weight. Include head-circumference measurements until the age of two years. Measurements must be plotted on appropriate growth charts. Screen for healthy weight using the Centers for Disease Control and Prevention (CDC) body mass index (BMI) charts for members aged two through 20 years of age; blood pressure at age three years and older; sensory screening, including vision and hearing; oral-health assessment; and pelvic examination for female members within three years after their first sexual intercourse but no later than age 21 years of age and thereafter every year. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules Page W-2 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 Nutritional Assessment Each EPSDT and PPHSD visit must include an evaluation of the member's nutritional health, including (a) medical history; (b) dietary habits; (c) physical examination; (d) height, weight, and BMI; (e) head-circumference measurements, as appropriate; (f) laboratory tests to screen for iron deficiency and elevated cholesterol, if indicated; and (g) infant nutrition including support for breastfeeding, if indicated. Providers must make every effort to inform the member or his or her parent or guardian about the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), if the provider believes that the child may be eligible for WIC. A referral to WIC should be made using the WIC Medical Referral Form (MRF) from the Massachusetts WIC Program. The member, parent, or guardian may also be referred to the Supplemental Nutrition Assistance Program (SNAP), which is administered by the Department of Transitional Assistance. Developmental Screening and Behavioral Health Screening At each EPSDT or PPHSD visit, the provider must screen the member for delays or differences in functioning in the following areas, as appropriate to the member's age: (a) physical development, including gross motor development (strength, balance, and locomotion), fine motor development (hand-eye coordination), and sexual development; (b) cognitive development, including self-help and self-care skills and cognitive skills (problem-solving and reasoning abilities); (c) language development, including expression, comprehension, and articulation; (d) socialization and attachment indicators; and (e) psychosocial and behavioral development, including an assessment of social integration and peer relations, behavioral difficulties, such as sleep disturbances and aggression, psychological problems, such as depression, risk-taking behavior, and school performance. Essential components of the screening process include, but are not limited to (a) sensitive attention to member, parent, or guardian concerns about the member; (b) thoughtful inquiry about parent or guardian observations; (c) observation by the provider and the member’s parent or guardian about the member’s behaviors; (d) examination of specific developmental attainments; and (e) observation of member and parent or guardian interaction. In performing the developmental screening, the provider may utilize specific clinically appropriate developmental screening instruments including, but not limited to (a) Ages and Stages Questionnaire (ASQ); (b) Bayley Infant Neurodevelopmental Screener (BINS); (c) BRIGANCE screens; (d) Child Development Inventories; (e) Denver Developmental Screening Test II; (f) Early Language Milestone Scale; (g) Parents Evaluation of Developmental Status (PEDS); and (h) Parents Evaluation of Developmental Status: Developmental Milestones (PEDS: DM). Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules Page W-3 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 Providers must inform the parent or guardian about the benefits of developmental intervention and special education services if a concern is identified. To access these services for any member who is between birth and three years old, the member should be referred to the local Early Intervention program of the Massachusetts Department of Public Health. If the child is between two years six months and three years old, a referral to the local public school system should also be made. For children over the age of three, a referral should be made to the local public school system. Early Intervention and/or the local public school will conduct assessments to determine eligibility and service needs. In performing the behavioral health screening, providers must utilize a clinically appropriate tool from the following list of approved, standardized behavioral health screening tools: (a) Ages and Stages Questionnaires (ASQ: SE); (b) Brief Infant-Toddler Social and Emotional Assessment (BITSEA); (c) Car, Relax, Alone, Forget, Friends, Trouble, (CRAFFT) (screening for substance abuse); (d) Modified Checklist for Autism in Toddlers (M-CHAT) (screening for autism); (e) Parents’ Evaluation of Developmental Status (PEDS); (f) Patient Health Questionnaire-9 (PHQ-9) (screening for depression); (g) Pediatric Symptom Checklist (PSC) and Pediatric Symptom Checklist-Youth Report (Y-PSC); and (h) Strengths and Difficulties Questionnaire (SDQ) If there is evidence of a behavioral health concern, or need for further assessment, providers must offer the necessary behavioral health services or make a referral to another provider who can provide the appropriate services. Providers can seek assistance from MassHealth or a member’s health plan to determine what providers may be available to provide these services and how to utilize out of network providers, if necessary. Hearing Screening – An objective hearing screening must be performed using an audiometer or otoacoustic emissions at the following frequencies: 1,000 Hz, 2,000 Hz, and 4,000 Hz tones at 20 dB HL, at the following ages: four years, five years, six years, eight years, 10 years, 12 years, 15 years, and 17 years. If the objective hearing screen is performed in another setting, such as a school, the screening does not need to be repeated by the provider, but the findings must be documented in the member's medical record. Conduct a subjective hearing assessment at all other routine checkups. Conduct audiologic monitoring every six months until the age of three years if there is a language delay or risk of hearing loss. If the provider receives notification of a missed or failed newborn hearing screen, then the provider should ensure that a new screening or diagnostic follow up takes place. Providers should contact the Massachusetts Department of Public Health’s Universal Newborn Hearing Screening Program for additional information about the newborn hearing screening. Vision Screening Assess newborns before discharge or at least by the age of two weeks, including corneal light reflex and red reflex. Evaluate fixation preference, alignment, and eye disease by the age of six months and at each subsequent well-child visit. Screen for strabismus between the ages of three years and five years. An objective vision acuity screening must be performed at the following ages: three years, four years, five years, six years, eight years, 10 years, 12 years, 15 years, and 17 years. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules Page W-4 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 Screen children at entry to kindergarten if they have not been screened during the previous 12-month period (2004 MA law) using the Massachusetts Preschool Vision Screening Protocol. Children who fail to pass the vision screening and children with neurodevelopmental delay must be referred to a licensed optometrist or ophthalmologist. If the objective vision screen is performed in another setting, such as a school, the screen does not need to be repeated by the provider, but the findings must be documented in the member's medical record. Dental Assessment and Referral • Assess oral health at each visit. Intraoral assessments should identify obvious dental problems and ensure that regular visits to a dental provider are occurring. The screening provider must encourage members to seek regular dental care from a dental provider, at the eruption of the first tooth and no later than 12 months of age, including examinations once every six months, preventive services, and treatment, as necessary. Assess the need for fluoride supplementation starting at the age of six months continuing through four years of age. Counsel on good dental-hygiene habits, fluoride supplementation, and prevention of infant caries, including avoidance of bottle-propping. Cancer Screening and Examination Perform a Pap smear for female members within three years after their first sexual intercourse but no later than 21 years of age and thereafter at each EPSDT/PPHSD visit year. Perform a clinical breast exam and provide breast self-exam instruction starting at 20 years of age for female members. Perform a clinical testicular exam and provide self-exam instruction for male members annually beginning at the age of 15 years. Screen all members for the presence of other cancers as indicated by member or family history. Health Education and Anticipatory Guidance At every EPSDT or PPHSD visit, age-specific and appropriate counseling must be delivered to parents or guardians and members, if age-appropriate, about common and expected developmental advancements and common physical and behavioral concerns. Effective discussion includes assessment and teaching based on a family-centered, culturally competent approach, addressing the concerns of the members, parent(s), and guardian(s). Discussion topics should include, but not be limited to (a) developmental expectations and sound parenting practices; (b) behavioral risks, such as substance use, violence, and depression; (c) safe and healthy sexual behaviors, including abstinence and contraception with a sensitivity to sexual orientation; (d) benefits of a healthy diet, ways to achieve a healthy diet, and safe weight management; (e) benefits of physical activity, opportunities for daily physical activity, parents as role models; (f) impact of electronic media as a risk factor for being overweight, low school performance, and violent behavior. Encourage limiting of screen time. Discourage placement of computers and TVs in bedrooms; (g) chronic and communicable disease prevention; (h) safety measures and injury prevention, including car seats, bike helmets, poison prevention, gun safety, and other age-appropriate counseling; and Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules Page W-5 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 (i) use of sunscreen, minimizing exposure to the sun, and discouraging the use of tanning booths. Educational activities and resources (such as printed brochures, audiovisual materials, class instruction, and health-risk questionnaires) can enhance comprehensive child and adolescent health supervision, but should not replace interaction between the provider and the member. • Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents—Third Edition and the American Medical Association’s (AMA) Guidelines for Adolescent Preventive Services (GAPS) provide lists of topics that may be discussed, and resources for providers, parents, guardians, and members. Immunization Assessment and Administration – At every EPSDT or PPHSD visit, the provider must assess the member’s immunization status and administer all immunizations for which the member is due in accordance with the recommendations of the Department of Public Health’s Immunization Program. Lead Toxicity Screening – Providers must screen every member for lead toxicity according to the requirements for lead toxicity screening set forth by the Massachusetts Childhood Lead Poisoning Prevention Program (MCLPPP). Perform initial screening between nine and 12 months and again at two and three years of age. Screen at four years of age if a child lives in a city or town with a high risk for childhood lead poisoning. Screen at entry to kindergarten if not screened before. Children should be screened for lead poisoning more than once a year when they meet one of the high-risk criteria set forth by the MCLPPP or whenever in the sound medical judgment of the health care provider, they are at high risk of lead poisoning. A list of high-risk communities and additional information about screening can be found at www.mass.gov/dph/clppp. Pursuant to M.G.L. c. 111 § 191, physicians, other health care providers, and private laboratories must report all cases of childhood lead poisoning known to them to the Director within three working days of identification, unless previously reported. If a child suffers multiple episodes of lead poisoning, each episode must be reported. Tuberculin Test – The screening provider must assess a child’s risk at every periodic visit and administer a Mantoux test to children determined to be at high risk for contracting tuberculosis. Hematocrit or Hemoglobin Test The screening provider must obtain the hematocrit/hemoglobin test for iron deficiency according to the following: (a) once between nine months and 12 months of age; (b) as needed, at the clinician’s discretion for members aged one year through 10 years; and screen all non-pregnant adolescents every 5-10 years starting at 12 years of age and screen members 11 through 21 years of age annually, if at high risk. Cholesterol Screening – Screen children aged two years through 17 years at least once if they have a family history of premature cardiovascular disease or a parent with known lipid disorder and/or a parent with BMI greater than the 85th percentile. Screen once between the ages of 18 years and 21 years, if not screened previously. Urinalysis – Conduct once at about five years of age at the clinician’s discretion. Hepatitis C – Obtain anti-Hepatitis C virus test after the age of 12 months in children with mothers infected with hepatitis C virus and periodically test all children if at high risk. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules Page W-6 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 Sexually Transmitted Infections – Test all sexually active adolescents and young adults annually for gonorrhea and chlamydia, and screen for syphilis and any other sexually transmitted infections if the member is at risk. Counsel about the schedule of HPV vaccines. HIV –Routinely test adolescent and young adult males and females at increased risk. Advise about risk factors for HIV infection. Other Laboratory Testing – Obtain other laboratory tests according to the member’s risk, the provider's professional judgment, and applicable state requirements for newborn screening tests. The Dental Schedule The EPSDT Dental Protocol and Periodicity Schedule (the Dental Schedule) consists of procedures arranged according to the intervals or age levels at which each procedure is to be provided. The Dental Schedule is based on the Preventive Pediatric Oral Health Care recommendations from the American Academy of Pediatric Dentistry (AAPD) Reference Manual 2007-2008. See 130 CMR 450.140 through 450.150 for more information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) services. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules * Page W-7 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 Recommendations for Preventive Pediatric Oral Health Care (AAPD Reference Manual 2007-2008) 6 - 12 Months 12 - 24 Months 2 - 6 Years 6 - 12 Years 12 -20 Years Clinical oral examination (1,2) x x x x x Assess oral growth and development (3) x x x x x Caries-risk assessment (4) x x x x x Radiographic assessment (5) x x x x x Prophylaxis and topical fluoride (4,5) x x x x x Fluoride supplementation (6,7) x x x x x Anticipatory guidance/counseling (8) x x x x x Oral hygiene counseling (9) Parent Parent Patient/parent Patient/parent Patient Dietary counseling (10) x x x x x Injury prevention counseling (11) x x x x x Counseling for nonnutritive habits (12) x x x x x Counseling for speech/language development x x x Substance abuse screening x x Screening for intraoral/perioral piercing x x Assessment and treatment of developing malocclusion x x x Assessment for pit and fissure sealants (13) x x x Assessment and/or removal of third molars x Transition to adult dental care x 1. First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as indicated by child’s risk status/susceptibility to disease. 2. Includes assessment of pathology and injuries. 3. By clinical examination. 4. Must be repeated regularly and frequently to maximize effectiveness. 5. Timing, selection, and frequency determined by child’s history, clinical findings, and susceptibility to oral disease. 6. Consider when systematic fluoride exposure is suboptimal. 7. Up to at least 16 years. 8. Appropriate discussion and counseling should be an integral part of each visit for care. 9. Initially, responsibility of parent; as child develops, jointly with parent; then, when indicated, only child. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules Page W-8 All Provider Manuals Transmittal Letter ALL-171 Date 11/01/09 10. At every appointment; initially discuss appropriate feeding practices, then the role of refined carbohydrates and frequency of snacking in caries development and childhood obesity. 11. Initially play objects, pacifiers, car seats; then when learning to walk, sports and routine playing, including the importance of mouthguards. 12. At first, discuss the need for additional sucking; digits vs. pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism. 13. For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed as soon as possible after eruption.