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MassHealth Guidelines for Medical Necessity Determination for Adult Day Health (ADH) Services

The MassHealth Guidelines for Medical Necessity Determination (Guidelines) are used by MassHealth's reviewing clinicians to determine the medical necessity of prior-authorization requests submitted by providers.

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Guidelines for Medical Necessity Determination for Adult Day Health (ADH) Services

These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information that MassHealth uses to determine medical necessity for Adult Day Health (ADH) services. These Guidelines are based on generally accepted standards of practice, review of medical literature, and federal and state policies and laws applicable to Medicaid programs.

MassHealth ADH providers (Providers) should consult MassHealth regulations at 130 CMR 404.000:  Adult Day Health Services and 101 CMR 310.00: Rates for Adult Day Health Services and the MassHealth Adult Day Health (ADH) Manual for information about coverage, limitations, service conditions, and Prior-Authorization (PA) requirements. Providers serving members enrolled in a MassHealth-contracted accountable care partnership plan (ACPP), managed care organization (MCO), integrated care organization (ICO), senior care organization (SCO), or program of all-inclusive care for the elderly (PACE) should refer to the ACPP’s, MCO’s, ICO’s, SCO’s or PACE’s medical policies for covered services.

MassHealth requires PA (see Section III) for ADH services. MassHealth reviews requests for PA on the basis of medical necessity. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, MassHealths administrative and billing regulations and guidance, and MassHealths ADH program regulations and guidance.

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