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MassHealth Guidelines for Medical Necessity Determination for Day Habilitation

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 Day Habilitation

These Guidelines for Medical Necessity Determination identify the clinical information that MassHealth uses to establish medical necessity of prior authorization (PA) requests for Day Habilitation (DH), including Individualized Staffing Supports (ISS) level of service. 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 DH providers should consult MassHealth regulations at 130 CMR 419.000 and 101 CMR 348.00, MassHealth DH bulletins, and the MassHealth Day Habilitation Provider Manual for information about coverage, limitations, service conditions, and PA requirements. Providers serving members enrolled in the Senior Care Options (SCO) or the Program of All-inclusive Care for the Elderly (PACE) should refer to the SCO or PACE medical policies for covered services.

MassHealth requires PA (see Section III) for DH, including the ISS service level. MassHealth reviews requests for PA based on medical necessity. If MassHealth approves the request for PA, payment of claims is still subject to all general conditions of MassHealth, including member eligibility, other insurance, MassHealth’s administrative and billing regulations and guidance, and MassHealth’s DH program regulations and guidance.

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