130 CMR, § 419.407

Current through Register 1536, December 6, 2024

Section 419.407 - Service Needs Assessment, Leveling Tool, and Prior Authorization

(A) A Service Needs Assessment (SNA) is completed by the clinical members of the IDT and determines a member's functional level, needs, and strengths, and makes specific recommendations to address acquisition, improvement, or maintenance of each identified need area for the member. Each SNA must

(1) be completed within 45 business days of a member's admission and every two years thereafter and upon a significant change in the member's condition;

(2) assess each of the following need areas: self-help skills, sensorimotor skills, communication skills, independent living skills, affective development skills, social development skills, behavioral development skills, and wellness; and

(3) identify which need areas will be addressed in the DHSP.

(4)Assessment Criteria. Providers must include the following as part of the initial assessment or reassessment of a member:

(a) confirmation that the member had a physical examination or wellness visit by a PCP within 12 months before the start of DH services; and

(b) a certification, signed by a PCP, supporting the diagnosis of ID or DD.

(B)Leveling Tool. Using the results of the SNA, a DH provider must identify the member's appropriate DH service level and acquire Prior Authorization (PA). The Leveling Tool will identify a member as Level 1, Level 2, Level 3, or Level 4. A new Leveling Tool is required, along with a new SNA, every two years or sooner if the member experiences a significant change.

(C)Prior Authorization.

(1) A DH provider must obtain PA from the MassHealth agency or its designee as a prerequisite to payment for the provision of DH upon admission, every two years thereafter, and upon significant change.

(2) PA determines the medical necessity for DH as described under 130 CMR 419.406 and in accordance with 130 CMR 450.204: Medical Necessity.

(3) PA specifies the level of payment for the service.

(a) The MassHealth agency pays DH providers for DH provided from the first date on which services are authorized through PA in the form and format required.

(b) PA through the MassHealth agency authorizes DH providers to claim for DH services provided to an eligible member at one of four levels of payment reflecting the member's assessed need for DH.

(4) PA does not establish or waive any other prerequisites for payment such as the member's financial eligibility described in 130 CMR 503.007: Potential Sources of Health Care and 130 CMR 517.008: Potential Sources of Health Care.

(5) When submitting a request for PA for payment of DH to the MassHealth agency or its designee, the DH provider must submit requests in the form and format as required by the MassHealth agency. The DH provider must include all required information, including, but not limited to, documentation of the completed SNA, Leveling Tool, other nursing, medical, or psychosocial evaluations or assessments, and any other additional assessments, documentation, or information that the MassHealth agency, or its designee, requests in order to complete the review and determination of PA.

(6) In making its prior authorization determination, the MassHealth agency or its designee may require additional assessments of the member or require other necessary information in support of the request for prior authorization.

(7) When submitting a request for PA for members living in an NF, the DH provider must submit the Level II PASRR.

(8) When submitting a request for PA for members who demonstrate medical necessity for one-to-one nursing for all six program hours, the DH provider must provide additional documentation in the form and format designated by the MassHealth agency.

(D)Notice of Determination of Prior Authorization.

(1)Notice of Approval. If the MassHealth agency or its designee approves a request for prior authorization, it will send written notice to the member and the DH provider.

(2)Notice of Denial or Service Modification. If the MassHealth agency or its designee denies, or modifies, a request for prior authorization of DH, the MassHealth agency or its designee will notify both the member and the DH provider. The notice will state the reason for the denial or service modification and contain information about the member's right to appeal and the appeal procedure.

(3)Right of Appeal. A member may appeal a service denial or modification by requesting a fair hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules.

(E)Review. The MassHealth agency, or its designee, may at any time review the medical necessity of the provision of DH to MassHealth members, including, but not limited to, instances in which there has been a significant change in the member's status as defined in 130 CMR 419.402.