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.
Guide MassHealth Guidelines for Medical Necessity Determination for Home Health Services
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Guidelines for Medical Necessity Determination for Home Health Services
These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information that MassHealth uses to determine medical necessity for Home Health 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 Home Health Agency providers (“Providers”) should consult MassHealth regulations at 130 CMR 403.000 and 101 CMR 350.00 for information about coverage, limitations, service conditions, and prior-authorization 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 prior authorization for Home Health Services defined as skilled nursing visits, continuous skilled nursing, physical therapy, occupational therapy, speech-language therapy, and home health aide services provided in the patient’s home. MassHealth reviews requests for prior authorization 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, and program restrictions.