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 TRANSMITTAL LETTER SHC-14 January 2004 TO: Speech and Hearing Centers Participating in MassHealth FROM: Beth Waldman, Acting Commissioner RE: Speech and Hearing Center Manual (Prior Authorization for Certain Therapy Visits) This letter transmits revisions to the speech and hearing regulations about therapy services. Effective February 1, 2004, a provider must obtain prior authorization from MassHealth before providing more than 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 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 12month 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 15 visits that are allowed without prior authorization. No payment is made for services in excess of 15 speech/language therapy visits to a provider in a 12-month period, unless prior authorization has been obtained from MassHealth. Example: If a member’s first speech/language therapy visit after February 1, 2004, is March 22, 2004, then the 12-month period for therapy is March 22, 2004, through March 21, 2005. MassHealth will pay the provider for seven additional 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. Exception: If a member is receiving therapy under a prior authorization given by MassHealth before February 1, 2004, MassHealth will not count visits authorized by that prior authorization toward the initial 15 visits allowed without prior authorization. Rather, after the number of visits approved before February 1, 2004, are provided, or after the prior authorization expires, whichever is sooner, a member may receive 15 therapy visits within a 12-month period before the provider must request another prior authorization. Example: If a member is receiving speech/language therapy under a prior authorization that was issued before February 1, 2004, and that expires on May 15, 2005, then the 12month period for speech/language therapy begins on the date of the first visit after the date the prior authorization expires. If this member’s next speech/language therapy visit is May 20, 2004, then the 12-month period in this example begins on May 20, 2004. MassHealth will pay for a total of 15 speech/language therapy visits between May 20, 2004, and May 19, 2005, without prior authorization. MASSHEALTH TRANSMITTAL LETTER SHC-14 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. If you are using APAS, you can either download this MassHealth form, 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 speech and hearing 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 SHC-14 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.) Speech and Hearing Center Manual Pages iv, vii, and 4-1 through 4-8 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Speech and Hearing Center Manual Pages iv, vii, and 4-1 through 4-8 — transmitted by Transmittal Letter SHC-12 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SPEECH AND HEARING CENTER MANUAL SUBCHAPTER NUMBER AND TITLE TABLE OF CONTENTS PAGE iv TRANSMITTAL LETTER SHC-14 DATE 02/01/04 4. PROGRAM REQUIREMENTS 413.401: Introduction ...................................................................................................... 4-1 413.402: Definitions ....................................................................................................... 4-1 413.403: Eligible Members............................................................................................... 4-2 413.404: Provider Eligibility .......................................................................................... 4-2 413.405: Services Provided by Out-of-State Providers .................................................... 4-3 413.406: Maximum Allowable Fees ............................................................................... 4-3 413.407: Individual Consideration .................................................................................. 4-3 413.408: Prior Authorization .......................................................................................... 4-4 (130 CMR 413.409 through 413.415 Reserved) 413.416: Payable Services .............................................................................................. 4-5 413.417: Nonpayable Services ........................................................................................ 4-6 413.418: Service Limitations .......................................................................................... 4-6 413.419: Medical Referral Requirements ....................................................................... 4-6 413.420: Recordkeeping Requirements .......................................................................... 4-7 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE PREFACE PAGE vii SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-14 DATE 02/01/04 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. Each manual in the series contains administrative regulations, billing regulations, program regulations, service codes and descriptions, billing instructions, and general information. MassHealth’s 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. Regulations promulgated by MassHealth are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. 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 provider manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For speech and hearing centers, those matters are covered in 130 CMR Chapter 413.000, reproduced as Subchapter 4 in the Speech and Hearing Center Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which provide instructions for making changes by hand ("pen-and-ink" revisions), and by 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 with MassHealth members. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 413.000) PAGE 4-1 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-14 DATE 02/01/04 413.401: Introduction All speech and hearing centers participating in MassHealth must comply with MassHealth regulations, including but not limited to 130 CMR 413.000 and 450.000. 413.402: Definitions The following terms used in 130 CMR 413.000 have the meanings given in 130 CMR 413.402, unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 413.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 403.000 and in 130 CMR 450.000. Audiological Services — these services include, but are not limited to, testing related to the determination of hearing loss, evaluation of hearing aids, prescription of hearing aid devices, and aural rehabilitation. Audiologist — a person licensed by the Massachusetts Division of Registration in Speech Language Pathology and Audiology and certified by the American Speech-Language-Hearing Association (ASHA). Auditory Training — the training of the auditory modality to improve understanding of the speech or language of other speakers. Auditory training is one of the components of aural rehabilitation. Aural Rehabilitation — therapy, including, but not limited to, speech reading and auditory training, provided by a licensed certified audiologist or a licensed certified speech therapist either in a group or individually. Complete Audiological Evaluation — an evaluation that includes a routine audiological examination (air and bone conduction, spondee thresholds, and word-discrimination testing) and site-of-lesion testing (middle-ear testing or recruitment testing, or both, with analysis) as recommended by a physician. Comprehensive Evaluation — an in-depth assessment of a member’s medical condition, disability, and level of functioning to determine the need for treatment and, when treatment is indicated, to develop a treatment plan. Group Therapy — therapeutic services provided to more than one patient but less than seven patients in a single encounter, using group participation as a treatment technique. Hearing Aid Evaluation — a procedure conducted by an audiologist that may include: (1) an assessment of the member’s performance by appropriate tests (functional gain or real ear measurements, or both); (2) if a hearing aid is prescribed, a recheck of the member and hearing aid after the prescribed hearing aid has been fitted; and (3) if a hearing aid is prescribed, counseling related to the member’s adjustment to the use of the hearing aid. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 413.000) PAGE 4-2 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-14 DATE 02/01/04 Maintenance Program — repetitive activities intended to maintain function that can be performed safely and effectively without the skilled assistance of a qualified therapist. Routine Audiological Evaluation — a procedure that includes: (1) a pure-tone audiogram, by air and bone conduction testing; and (2) speech threshold and discrimination testing. Speech and Language Pathology Services — the evaluation and treatment of communicative disorders with regard to the functions of articulation (including apraxia and dysarthria), language, voice, and fluency. Speech Reading — the training of the visual modality to improve the understanding of the speech or language of other speakers. Speech reading is one of the components of aural rehabilitation. Speech Therapist — a person currently licensed by the Massachusetts Division of Registration in Speech/Language Pathology and Audiology with a Certificate of Clinical Competence from the American Speech Language Hearing Association (ASHA). 413.403: Eligible Members (A) (1) MassHealth Members. MassHealth covers audiological and hearing aid services when provided to eligible MassHealth members, subject to the restrictions and limitations described in 130 CMR 413.000 and 450.000. 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. 413.404: Provider Eligibility (A) In State. To be eligible to participate in MassHealth, a speech and hearing center must currently: (1) be licensed by the Massachusetts Department of Public Health; (2) be certified by the American Speech-Language-Hearing Association (ASHA); (3) not be a part of a hospital; (4) provide authorized speech, hearing, or language services provided by a licensed, certified audiologist or a licensed, certified speech therapist who does not bill separately from such facility for professional services; and (5) meet the requirements of 130 CMR 450.212. (B) Out of State. A speech and hearing center located outside Massachusetts is eligible to participate in MassHealth only if the speech and hearing center is licensed to practice by the appropriate state's board of registration and meets the requirements of 130 CMR 413.404(A)(2) and 450.212. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 413.000) PAGE 4-3 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-14 DATE 02/01/04 413.405: Services Provided by Out-of-State Providers In accordance with 42 CFR 431.52(b), MassHealth pays for out-of-state speech and hearing center services only in the following circumstance: (A) services are needed and the member’s health would be endangered if the member were required to travel to his or her state of residence; (B) MassHealth determines, on the basis of medical advice, that the needed services, or necessary supplementary resources, are more readily available in another state; or (C) as a general practice, members in a particular locality use medical resources in another state. 413.406: Maximum Allowable Fees MassHealth pays the lowest of the following for speech and language pathology services, audiological services, hearing aids, and related batteries and accessories: (A) the speech and hearing center's usual and customary fee; (B) the charge the speech and hearing center has submitted to MassHealth on the claim form; or (C) the maximum fee listed in the applicable fee schedule of the Massachusetts Division of Health Care Finance and Policy. 413.407: Individual Consideration Services designated "I.C." in the list of service codes and descriptions in Subchapter 6 of the Speech and Hearing Center Manual are given individual consideration to determine the amount of payment. The amount of payment is determined by using the following criteria: (A) the time required to perform the procedure; (B) the degree of skill required to perform the procedure; (C) the severity or complexity of the member's hearing disorder or disability; (D) the policies, procedures, and practices of other third-party purchasers of health care; and (E) the reasonable and customary practices of speech and hearing centers. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 413.000) PAGE 4-4 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-14 DATE 02/01/04 413.408: Prior Authorization (A) Services designated "P.A." in the list of service codes and descriptions in Subchapter 6 of the Speech and Hearing Center Manual require prior authorization from MassHealth. Such services include, but are not limited to: (1) more than 15 speech and language pathology visits, including an evaluation and group-therapy visits, for a member in a 12-month period; (2) continuing therapy when payment has been discontinued by any other third-party payer, including Medicare; and (3) a second comprehensive evaluation in a 12-month period for a member whose level of functioning has decreased significantly or whose diagnosis has changed. (B) All prior-authorization requests must be submitted in accordance with the billing instructions in Subchapter 5 of the Speech and Hearing 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. (130 CMR 413.409 through 130 CMR 413.415 Reserved) 413.416: Payable Services Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 413.000) PAGE 4-5 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-14 DATE 02/01/04 (A) Comprehensive Evaluation. Payment for a comprehensive evaluation includes the preparation of a written report for the member's medical record that contains at least the following information: (1) the member's name and address; (2) the name of the referring physician; (3) a detailed treatment plan prescribing the type, amount, frequency, and duration of the therapy and indicating the diagnosis, anticipated goals, and location where therapy will take place, or the reason treatment is not indicated; (4) a description of any conferences with the member, the member’s family, the member’s physician, or other interested persons; (5) other health-care evaluations, as indicated; (6) a description of the member's psychosocial and health status that includes: (a) the present effects of the disability on the member and his or her family; (b) a brief history, the date of onset, and any past treatment of the disability; (c) the member's level of functioning, both current and before onset of the disability, if applicable; and (d) any other significant physical or mental disability that may affect therapy; (7) assessment of articulation, stimulability, voice, fluency, and receptive and expressive language; (8) documentation of the member's cognitive functioning; (9) a description of the member's communication needs and motivation for treatment; and (10) the therapist's signature and the date of the evaluation. (B) Group Therapy. MassHealth pays for therapy provided to a member in a group consisting of more than two but less than seven persons, subject to the restrictions and limitations of 130 CMR 413.000. (C) Complete Audiological Evaluation. MassHealth pays for a complete audiological evaluation only if it is prescribed by a physician in writing, subject to the restrictions and limitations of 130 CMR 413.000. (D) Earmold. An earmold is not payable if it is included in the manufacturer's price of the hearing aid or if the member already has an appropriate earmold. Payment for an earmold includes the following: (1) the ear impression; (2) the proper fitting of the earmold; and (3) any adjustments that may be needed during the operational life of the earmold. (E) Ear Impression. Payment for an ear impression includes one properly formed ear impression for each in-the-ear hearing aid purchased and is allowed only at the time of purchase of the hearing aid. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 413.000) PAGE 4-6 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-14 DATE 02/01/04 413.417: Nonpayable Services MassHealth does not pay for any of the following services: (A) services provided by any person under the supervision of the speech therapist or audiologist; (B) indirect services such as staff meetings, staff supervision, member screening, and development or use of instructional texts and reusable treatment materials; (C) nonmedical services such as vocational, social, and recreational services; (D) research or experimental treatment; (E) mental health services; (F) 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; and (G) the rental of hearing aids. 413.418: Service Limitations (A) MassHealth pays the speech and hearing centers for no more than one individual treatment and one group therapy session per member per day. (B) MassHealth does not pay for a treatment claimed for the same date of service as a comprehensive evaluation, since the evaluation fee includes payment for both a written report and for any treatment provided at the time of the evaluation. (C) MassHealth pays speech and hearing centers for providing therapy services in a Medicare-certified long-term-care facility only in the following circumstances. (1) The member is not covered under Medicare Part A or B. (2) The member is covered under Medicare, the facility has submitted the claim to Medicare, and Medicare has denied payment. 413.419: Medical Referral Requirements (A) MassHealth pays only for those treatments and evaluations for which the speech and hearing center has obtained written referral from a licensed physician. The referral must include the following information: (1) a complete diagnosis of the member; (2) the date of onset of the disability for which therapy is recommended; (3) a statement of previous treatment, if any; (4) the date of the member's last physical examination; (5) the reason for the referral; (6) the date of the referral; and (7) the physician's signature and address. (B) A referral from the physician does not authorize payment. The speech therapy or aural rehabilitation prescribed by the physician pursuant to the comprehensive evaluation described in 130 CMR 413.416(A) must constitute appropriate and effective treatment, within accepted medical standards, for the member's condition. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 413.000) PAGE 4-7 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-14 DATE 02/01/04 413.420: Recordkeeping Requirements The speech and hearing center must maintain a health-care service record for each member for a period of at least four years following the date of service. The record must contain all pertinent information about the services provided, including the date of service and the dates on which materials were ordered and dispensed. The record must include the following: (A) a licensed physician's written and dated referral for evaluation and referral for treatment, if applicable; (B) the written comprehensive evaluation report (see 130 CMR 413.416(A)); (C) the name, address, and telephone number of the member’s primary care physician; and (D) at least weekly documentation of the following: (1) the date or dates of which speech therapy or aural rehabilitation was provided; (2) the specific therapeutic procedures and methods used; (3) the member’s response to treatment; (4) any changes in the member’s condition; (5) the problems encountered or changes in the treatment plan or goals, if any; (6) the location where the service was provided, if different from that in the evaluation report; (7) the amount of time spent in treatment; and (8) the speech therapist's signature. REGULATORY AUTHORITY 130 CMR 413.000: M.G.L. c. 118E, ss. 7 and 12. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 413.000) PAGE 4-8 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-14 DATE 02/01/04 THIS PAGE IS RESERVED.