These Guidelines for Medical Necessity Determination (Guidelines) identifies the clinical information MassHealth needs to determine medical necessity for Community Support Program (CSP) services. These Guidelines are based on generally accepted standards of practice and federal and state policies and laws applicable to Medicaid programs.
Providers should consult MassHealth regulations at 130 CMR 450.000 (All Providers) and 130 CMR 461.000 (Community Support Program Services) for information about coverage, service limitations, and requirements applicable to this service.
Providers serving members enrolled in a MassHealth-contracted Managed Care Organization, Accountable Care Partnership Plan, One Care plan, or Senior Care Options (SCO) plan should refer to the ACPP’s, MCO’s, One Care plan’s, or SCO’s medical policies for covered services. Providers serving members enrolled in a MassHealth-contracted Primary Care Accountable Care Organization, the state’s Primary Care Clinician Plan, or the MassHealth-contracted behavioral health vendor should refer to the MassHealth-contracted behavioral health vendor’s medical policies for covered services. Additional information may be found in MCE Bulletin 99.
No prior authorization is required for CSP services. Payment for CSP services is subject to all general conditions of MassHealth, including member eligibility, other insurance, and program restrictions.