These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine if medical necessity for speech-language therapy services performed in outpatient and home settings are medically necessary. 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.
Providers should consult MassHealth regulations at 130 CMR 450.000 (All Providers), 432.000 (Independent Therapists), 410.000 (Outpatient Hospitals), 430.000 (Rehabilitation Centers), 403.000 (Home Health Agencies), 413.000 (Speech and Hearing Centers), and 433.000 (Physicians), for information about coverage, service limitations, and prior-authorization requirements applicable to this service.
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.
If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other insurance, and program restrictions.