These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information that MassHealth needs to determine medical necessity for hospital beds/specialized pediatric beds used in the home. These Guidelines are based on generally accepted standards of practice, review of the medical literature, and federal and state policies and laws applicable to Medicaid programs.
Providers should consult MassHealth regulations at 130 CMR 409.000 and 450.000, Subchapter 6 of the Durable Medical Equipment Manual, and the MassHealth DME and Oxygen Payment and Coverage Guidelines Tool 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 all hospital beds. 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.