Provider Manual6: Specific Provider Information
This section describes Commonwealth Care Alliance's protocols regarding non-acute care facilities and ancillary providers. The protocols include covered services, exclusions, clinical conditions and criteria, authorizations and operational expectations. The majority of services provided must be approved by the member's Commonwealth Care Alliance designated primary care physician/primary care team (PCP/PCT). Prior authorization is required and shall be granted from Commonwealth Care Alliance's designated PCP/PCT authorizing the provider to render specified covered services to a Commonwealth Care Alliance member. Payment to facility for covered services requiring prior authorization is contingent upon the provider receiving prior authorization before services are rendered. Click here to view the Covered Services and Prior Authorization grid. Additionally, if the provider offers Durable Medical Equipment (DME) or vision services, please visit Durable Medical Equipment & Supplies and Vision sections of this Provider Manual for specific authorizations requirements. Eligibility must be confirmed on a regular basis, even if the prior authorization covers a longer period. Eligibility may be confirmed by utilizing the current MassHealth Provider Online Service Center. Extended Care Facility ServicesCovered Services Those extended care facility services to which a member is entitled and which are consistent with provider training, licensure, and scope of business. Extended Care Facility Services Services are defined as nursing, medical social work, assistance with activities of daily living, rehabilitation therapies, nutrition, and medications. Services shall include, at a minimum, room with customary furnishings and equipment (one or more beds per room), meals (including special diets and nutritional supplements as medically necessary), general nursing care, and recreational services. For covered services provided to Commonwealth Care Alliance members, facility will be paid according to the member's level of care needs that corresponds to the sub-acute, skilled nursing, or custodial care category described below, as determined by Commonwealth Care Alliance's clinical operations team or PCT team. Sub-Acute Care Inclusions Room and board, skilled nursing care, rehabilitation services, laboratory, x-ray, medical & surgical supplies, oxygen and associated supplies, standard DME, medications. For billing purposes, please use Revenue Code 192. Exclusions Physician services (professional component only), dialysis, ambulance (covered only as part of admit and discharge from skilled nursing facility), emergency room. Conditions & Criteria for the Assignment of Sub-Acute Level of Care Conditions There has been a determination by the Commonwealth Care Alliance clinical operations team or PCT that a short term, goal oriented treatment plan is necessary; the member requires nursing care and/or rehabilitation at a higher intensity than the skilled level of care. Criteria Care is at a sub-acute level when the following criteria are met:
Skilled Care Inclusions Room and board, skilled nursing care, rehabilitation service, laboratory, x-ray, medical & surgical supplies, oxygen & associated supplies, standard DME, medications. For billing purposes, please use Revenue Code 191. Exclusions Physician services, dialysis, emergency room, and ambulance. Ambulance is covered only as part of admit and discharge from skilled nursing facility or if warranted during the stay to transport to appointments or treatments. Conditions & Criteria for the Assignment of Skilled Nursing Level of Care Conditions There has been a determination by the Commonwealth Care Alliance clinical operations team or PCT that a goal oriented treatment plan is necessary and that the member cannot, as a practical matter, be treated in a community based setting; member requires skilled nursing care and/or skilled rehabilitation; such care is needed on a daily basis, at least five days per week. Criteria Care is at a skilled nursing level when the following criteria are met:
Custodial Care Inclusions Room and board, skilled nursing care, laboratory, x-ray, medical & surgical supplies, oxygen & associated supplies and standard DME are included services. For billing purposes, please use Revenue Code 120.Exclusions Physician services, dialysis, emergency room, and ambulance. Ambulance is covered only as part of admit and discharge from skilled nursing facility or if warranted during the stay to transport to appointments or treatments. Medications may be excluded and billed separately through informedRX. Conditions & Criteria for the Assignment of Custodial Care Level of Care Conditions There has been a determination by the Commonwealth Care Alliance clinical operations staff or the PCT that there is an absence of a defined skilled need or treatment goal that the member is expected to achieve; the member's functional or cognitive status is such that the support of a facility setting is necessary, as member cannot be safely managed in the community with long term care supports. Criteria Care is at a custodial care level when the following criteria are met:
Benefit Exhaustion of Sub-Acute Care and Skilled Care If during an admission the exhaustion of a member's Medicare skilled nursing benefit occurs, Commonwealth Care Alliance reimbursement shall default to provider's usual and customary Medicaid reimbursed MMQ rates, based on the member's MMQ score, for skilled nursing facility placement less the applicable MassHealth determined monthly member paid amount.Readmissions Member readmission to facility after formal discharge shall require re-establishing a member's admitting level of care by Commonwealth Care Alliance clinical operations staff, PCT and/or those designated and authorized by Commonwealth Care Alliance to direct member care. Level of Care Determinations All level of care determinations prior to, and during Commonwealth Care Alliance a member's admission to a facility are made at the discretion of Commonwealth Care Alliance nursing staff and/or those designated and authorized by Commonwealth Care Alliance to direct member care. Medical Leave of Absence (MLOA) days and Non- Medical Leave of Absence (NMLOA) days will be paid an amount equal to the provider's current Medicaid reimbursement rate for up to 10 days with the prior approval of the member's Commonwealth Care Alliance contracted PCP/PCT. It is further understood, and agreed, that a bed is guaranteed for the member if s/he returns to the facility during the 1st day through the 10th day after transfer out of the facility. If the member returns after this period, his/her admission shall be accommodated upon the availability of a bed, unless otherwise arranged. For billing purposes of Custodial MLOA, please use Revenue Code 185. For billing purposes of Custodial NMLOA, please use Revenue Code 183. Service Specifications The extended care facility services provider shall:
Event Triggers and Required Forms: Admissions and Discharges from Nursing Facilities When a SCO community enrollee is admitted to a nursing facility, nursing facility must submit a Status Change Form (SC-1) to Commonwealth Care Alliance and the appropriate member enrollment center with "SCO Member" clearly indicated on the form. Additional requirements can be found in the table below. Short Term Stays
Short Term Discharges
Long Term Stays
Long Term Discharges
Status Changes
Notes:*MMQs are also required on schedule assigned by MassHealth **Long term care screening form is not required to be completed for SCO members Regional Member Enrollment Centers45-47 Spruce StreetChelsea, MA 02150 Toll Free: 1-800-322-1448 Ph: 1-888-665-9993 Fax: (617) 887-8777 Please note when submitting or inquiring about a long term care applicant residing in a nursing facility serviced by the Chelsea MEC, please use this new fax number (617) 889-3285 333 Bridge StreetSpringfield, MA 01103 Toll Free 1-800-332-5545 21 Spring Street, Suite 4 Taunton, MA 02780 Toll Free 1-800-242-1340 367 East Street Tewksbury, MA 01876 Toll Free 1-800-408-1253 Assisted Living Facilities: Specialized Personal Assistant (SPA)Covered Services In tandem with the member's housing, assisted living facilities provide:
*A member's ability to self-manage medication will be assessed as part of the initial assessment and a plan then will be developed inclusive of prescription and over the counter medication. Eligibility must be confirmed on a regular basis, even if the prior authorization covers a longer period. Eligibility may be confirmed by utilizing the current MassHealth Provider Online Service Center. Specialized Personal Assistant Specifications The assisted living facility specialized personal assistant shall:
Behavioral HealthCommonwealth Care Alliance in collaboration with the primary care team (PCT) is responsible to ensure that members have access to covered mental health services. Behavioral health problems are identified and addressed by the PCT using appropriate mental health screening tools. The PCT is required to refer members promptly for specialized behavioral health services. Members with serious and persistent mental health illness must have access to ongoing medication review and monitoring. Eligibility must be confirmed on a regular basis, even if the prior authorization covers a longer period. Eligibility may be confirmed by utilizing the current MassHealth Provider Online Service Center. Covered Services For Senior Care Options (SCO) members, covered behavioral health services fall into five categories as described below and are covered when authorized by the PCT:
Inpatient Services 24-hour services that provide medical intervention for mental health or substance abuse diagnoses, or both, including: Inpatient Mental Health Services Hospital services to stabilize an acute psychiatric condition that 1) has a relatively sudden onset; 2) has a short, severe course; 3) poses a significant danger to self or other; or 4) has resulted in marked psychosocial dysfunction or grave mental disability. Detoxification Inpatient substance abuse services that provide short term medical treatment for substance abuse withdrawal, individual medical assessment, evaluation, intervention, substance-abuse counseling, and post-detoxification referrals. These services may be provided in licensed freestanding or hospital-based programs. Diversionary Services Behavioral health services that are provided as alternatives to inpatient services including: Community Support Services provided in a community setting, which are used to prevent hospitalization, and designed to respond to the needs of members whose pattern of utilization of services or clinical profile indicates high risk of readmission into 24-hour treatment settings. Crisis Stabilization Services to provide an alternative to hospitalization, which provides short term psychiatric treatment in structured, community based therapeutic environments. Crisis stabilization provides continuous 24-hour observation and supervision for individuals who do not require the intensive medical treatment of hospital level of care. Observation/Holding Beds Services to provide hospital level care for up to 24 hours to provide time for assessment, stabilization, and identification of appropriate resources for individuals. Partial Hospitalization An alternative to inpatient mental health services, which offers short term day mental health programming available seven days per week consisting of therapeutically intensive acute treatment within a stable therapeutic milieu and including daily psychiatric management. Psychiatric Day Treatment Services that constitute a program of a planned combination of diagnostic, treatment, and rehabilitative services provided to mentally or emotionally disturbed persons who need more active or inclusive treatment than is typically available through a weekly visit to a mental health center, individual provider's office, or hospital outpatient department, but who do not need full-time hospitalization or institutionalization. Residential Substance Abuse Treatment Short term 24-hour therapeutically planned treatment and learning situation that provides continuity of care after detoxification for individuals engaging in recovery. Structured Outpatient Addiction Programs Short term clinically intensive structured day or evening substance-abuse services. Such a program can serve as a step-down service in the continuum of care for individuals being discharged from detoxification or can be utilized by individuals whose symptoms indicate a need for structured outpatient treatment beyond the standard outpatient benefit. Emergency Services Medically necessary services are available seven days per week, 24 hours per day to provide treatment of any member who is experiencing a mental health or substance abuse problem, or both, including: Emergency Screening Services A face-to-face assessment, conducted by appropriate clinical personnel, of an individual presenting with an emergency in a home, residential program, clinic, hospital emergency room, police station, and other settings. Medication Management Services Assessment for and prescribing of medication by qualified personnel as a component of emergency services. Short Term Crisis Counseling Provision of individual therapy as a component of emergency services. Short Term Crisis Stabilization Services Any or all of the following: 1) crisis stabilization; 2) observation/holding beds; 3) specializing services; 4) medication management services; and 5) short term crisis counseling. Specializing Services Therapeutic services provided to an individual, in a variety of settings, on a one-to-one basis to maintain the individual's safety as a component of emergency services. Outpatient Services Services provided in an ambulatory care setting, such as a mental health or substance abuse clinic, hospital outpatient department, community health center, or provider's office, including: Mental Health
Substance Abuse Services
Special Procedures Electro-Convulsive Therapy (ECT) Service that initiates seizure activity with an electric impulse while the member is under anesthesia. It is administered in a hospital facility that is licensed to provide this service by the Department of Mental Health. Psychological Neuropsychological Testing The use of standardized test instruments when indicated for behavioral or physical health reasons to evaluate aspects of a member's functioning, including but not limited to cognitive processes, emotional conflicts, and type and degree of psycho-pathology. Service Specifications The behavioral health provider shall:
Durable Medical Equipment & SuppliesCovered Services Those durable medical equipment and medical/surgical supplies which a member is entitled to and which are consistent with provider training, licensure and scope of business: Durable Medical Equipment Products that are a) fabricated primarily and customarily to fulfill a medical purpose; b) generally not useful in the absence of illness or injury; c) able to withstand repeated use over an extended period time; and d) appropriate for home use. Includes but is not limited to the purchase of medical equipment, replacement parts, and repairs for such items such as canes, crutches, wheelchairs (manual, motorized, custom fitted, and rentals), walkers, commodes, special beds, monitoring equipment, orthotic and prosthetic devices, and the rental of personal emergency response systems (PERS). Coverage includes related supplies, repair, and replacement of the equipment. Medical/Surgical Supplies Medical/treatment products that a) are fabricated primarily and customarily to fulfill a medical or surgical purpose; b) are used in the treatment of a specific medical condition; and c) are non-reusable and disposable. Includes but is not limited to items such as urinary catheters, wound dressings, glucose monitors, and diapers. All services provided must be approved by the member's PCT. Certain equipment and supplies may require prior authorization. For all other services prior authorization is required and shall be either a verbal or written authorization from Commonwealth Care Alliance's contracted primary care sites authorizing a provider to render specified covered services to a Commonwealth Care Alliance member. Payment to providers for those covered services requiring prior authorization is contingent upon the provider receiving prior authorization before services are rendered. Eligibility must be confirmed on a regular basis, even if the prior authorization covers a longer period. Eligibility may be confirmed by utilizing the current MassHealth Provider Online Service Center. Service Specifications for Durable Medical Equipment (DME) Commonwealth Care Alliance DME providers are responsible for meeting specified standards for hours of service and accessibility, repairs, and equipment. The standards are listed below: Emergently needed supplies are defined as services or equipment includes that which malfunctions or absence presents an immediate life-threatening situation. For example, oxygen and respiratory services and equipment are emergently needed supplies. Hours of Service and Accessibility
Repairs
Equipment
Rentals
DentalCovered Services Those dental services to which a member is entitled and which are consistent with provider training, licensure and the specific scope and conditions of covered services as referenced in the Provider Manual: Dental Services Including, but not limited to, emergency care visits, including x-rays; extractions; restorative services, dentures; and oral surgery. Services Specifications The dentist shall:
VisionCovered Services Those optometry/optician and vision supply services to which a member is entitled and which are consistent with provider training, licensure and specific scope and conditions of covered services as referenced in the Provider Manual. Optometry/Optician and Vision Supply Services Include the provision of prescriptive glasses and contact lenses, which may result from the receipt of professional care of the eyes for purposes of diagnosing and treating all pathological conditions through procedures such as eye examinations, vision training. All the services provided must be approved by the member's PCT. Prior authorization is required for Optometry/Optician and Vision Care. Services including but not limited to glasses and contact lenses and services related to the care and maintenance of glasses and contact lenses, and shall be granted by the member's Commonwealth Care Alliance's contracted PCS authorizing a provider to render specified covered services to a Commonwealth Care Alliance member. Payment to providers for covered services requiring prior authorization is contingent upon the provider receiving prior authorization before services are rendered. Eligibility must be confirmed on a regular basis, even if the prior authorization covers a longer period. Eligibility may be confirmed by utilizing the current MassHealth Provider Online Service Center. Service Specifications Hours of service and accessibility:
Repairs
Lenses/Frames
Documentation
Last Updated 5/2/12 |























