Section 404.414 - Conditions of Payment(A) The MassHealth agency pays an ADH provider for ADH in accordance with the applicable payment methodology and rate schedule established by EOHHS at 101 CMR 310.00: Adult Day Health Services. Rates of payment for ADH do not cover or include any amount for room and board.(B) Payment for ADH is subject to the conditions, exclusions, and limitations set forth in 130 CMR 404.000 and 450.000: Administrative and Billing Regulations.(C) The MassHealth agency pays ADH providers for ADH only if the(1) MassHealth agency or its designee determines that the ADH provided is medically necessary;(2) member meets the clinical eligibility criteria for MassHealth payment for ADH as described in 130 CMR 404.405;(3) ADH provider has obtained prior authorization for MassHealth payment for ADH in accordance with the requirements set forth in 130 CMR 404.406; and(4) ADH provider bills at the payment level authorized by the MassHealth agency or its designee.(D)ADH Payment Levels(1)Basic Payment Level(a) The MassHealth agency pays the Basic Payment Level rate to ADH providers for each date of service billed that the member meets the clinical eligibility criteria set forth in 130 CMR 404.405 and the provider meets at least one of the qualifying needs of the member while the member is in attendance at the ADH program.(b) The ADH provider must document how a qualifying need or needs were met for each member in a manner consistent with the member's plan of care on each date for which services are billed and make this information available to the MassHealth agency or its designee upon request. Such documentation must include evidence of the following having been provided pursuant to the member's plan of care, as applicable: daily ADL service delivery, daily behavior support or evaluation, daily activity participation, and/or evidence of skilled services care.(2)Complex Payment Level. (a) The MassHealth agency pays the Complex Payment Level rate for each date of service billed that the member meets the complex payment level criteria set forth in either 130 CMR 404.414(D)(2)(a)1. or 2., and the requirements of 130 CMR 404.414(D)(2) are 1. The member required the provision by the ADH provider of at least one skilled service from 130 CMR 404.405(B)(1) through B(5), or B(8) while in attendance at the ADH; or met:2. The member required the provision by the ADH provider of a combination of at least three of the following including at least one from 130 CMR 404.414(D)(2)(a)2.b.: a. qualifying activities of daily living listed at 130 CMR 404.405(C) performed while in attendance at the ADH; andb. skilled services listed at 130 CMR 404.405(B)(1) through B(5), B(8) through B(12), or B(15) required to be provided while in attendance at the ADH in a manner consistent with the plan of care as directed by the ADH nurse. (b) The ADH provider must maintain a minimum-staffing ratio of one staff person to four complex payment level members.(c) The ADH provider must document how qualifying needs and staffing needs set forth in 130 CMR 404.414(D)(2)(b) were met for each member in a manner consistent with the member's plan of care for each date for which services are billed and make this information available to the MassHealth agency or its designee upon request. Such documentation must include evidence of the following having been provided pursuant to the member's plan of care: daily ADL service delivery, daily behavior support or evaluation, daily activity participation, and evidence of skilled services care. (E)Transition Between Two ADH Providers. If a member changes from one ADH provider to another ADH provider, a new clinical assessment is required and the new ADH provider must obtain prior authorization prior to delivering services to the transferring member. The previous ADH provider must continue to provide ADH to the member while the new ADH provider is obtaining prior authorization and until the member is admitted and receiving services from the new ADH provider. The previous ADH provider must discharge the member from its ADH program before the new ADH provider may bill the MassHealth agency for ADH. The MassHealth agency will pay only one ADH provider per day for the provision of ADH to a member.(F) The ADH provider must review each member in its care to ensure that the clinical eligibility criteria for MassHealth payment for ADH continues to be met. An ADH provider must not bill and the MassHealth agency will not pay for ADH for any member who does not meet clinical eligibility criteria for MassHealth payment.(G) The ADH provider must bill the MassHealth agency only at the payment level authorized by the MassHealth agency or its designee.(H) The ADH provider must maintain documentation of delivered services in the member's medical record.(I) MassHealth payment to ADH providers begins on the later of:(1) the effective date of the prior authorization for services from the MassHealth agency; or(2) the first date on which ADH is provided to the member.(J) MassHealth payment to an ADH provider ends on the date which a member no longer meets the clinical requirements for MassHealth payment of ADH described in 130 CMR 404.405 or is no longer receiving ADH, whichever comes first.Amended by Mass Register Issue 1370, eff. 7/27/2018.Amended by Mass Register Issue 1372, eff. 7/27/2018.