Section 433.428 - Psychiatric Services: Introduction(A)Covered Services. The MassHealth agency pays a physician or a psychiatric clinical nurse specialist (PCNS) for the psychiatry services described in 130 CMR 433.428 and 130 CMR 433.429.(B)Non-covered Services.(1)Nonphysician and Non-PCNS Services. Except as permitted in Section 603 of Subchapter 6 of the Physician Manual, the MassHealth agency does not pay a physician or PCNS for services provided by a social worker, psychologist, or other nonphysician mental health professional employed or supervised by the physician or PCNS.(2)Research and Experimental Treatment. The MassHealth agency does not pay for research or experimental treatment. This includes, but is not limited to, any method not generally accepted or widely used in the field, or any session conducted for research rather than for a member's clinical need.(3)Nonmedical Services. The MassHealth agency does not pay a physician or PCNS for nonmedical services including, but not limited to, the following: (a) vocational rehabilitation services;(b) educational services;(c) recreational services (play therapy, the use of play activities with a child in an identified treatment setting as an alternative to strictly verbal expression of conflicts and feelings, is not considered a recreational service and is payable);(d) street-worker services (information, referral, and advocacy to certain age populations; liaison with other agencies; role modeling; and community organization); (e) life-enrichment services (ego-enhancing services such as workshops or educational courses provided to functioning persons); and(4)Nonmedical Programs. The MassHealth agency does not pay for diagnostic and treatment services that are provided as an integral part of a planned and comprehensive program that is organized to provide primarily nonmedical or other non-covered services. Such programs include freestanding alcohol or drug detoxification programs, freestanding methadone maintenance programs, residential programs, day activity programs, drop-in centers, and educational programs.(5)Psychological Testing. The MassHealth agency does not pay for psychological testing provided by a physician or a PCNS.(C)Services Provided by a Psychiatric Clinical Nurse Specialist (PCNS). (1)General. 130 CMR 433.428 and 130 CMR 433.429 apply specifically to physicians and psychiatric clinical nurse specialists. In general however, subject to compliance with state and federal law, the requirements and limitations elsewhere in 130 CMR 433.000 that apply to a physician, also apply to a psychiatric clinical nurse specialist (PCNS), such as service and payment limitations, recordkeeping and reporting requirements, and prior authorization and other conditions of coverage.(2)Conditions of Payment. The MassHealth agency pays a PCNS or group practice for PCNS services when(a) the services are limited to the scope of practice authorized by state law or regulation (including, but not limited to, 244 CMR: Board of Registration in Nursing or of the state licensing agency of another state in which the services are provided);(b) the PCNS or group practice is not an employee of the hospital or other facility in which the PCNS services were performed, or is not otherwise paid by the hospital or facility for the service;(c) the PCNS participates in MassHealth pursuant to the requirements of 130 CMR 433.428(C)(3); and(d) for an out-of-state PCNS, the requirements of 130 CMR 433.403(C) are met.(3)PCNS Provider Eligibility. Any PCNS applying to participate as a provider in MassHealth must submit documentation, satisfactory to the MassHealth agency, that he or she(a) is licensed to practice as a PCNS by the Massachusetts Board of Registration in Nursing or by the licensing agency of another state in which the PCNS services are provided; and(b) is a member of a group practice or is in a solo private practice.(4)Consultation Between a PCNS and a Physician. The MassHealth agency does not pay for a consultation between a PCNS and a physician as a separate service.(D)Record Keeping (Medical Records) Requirements. In addition to the provisions in 130 CMR 433.409, the following specific information must be included in the medical record for each member receiving psychiatric services: (1) the condition or reason for which psychiatric services are provided;(2) the member's diagnosis;(3) the member's medical history;(4) the member's social and occupational history;(6) the physician's or PCNS's short- and long-range goals for the member;(7) the member's response to treatment; and(8) if applicable, a copy of the signed consent for electroconvulsive therapy.(E)Frequency of Treatment. The MassHealth agency pays a physician for only one session of each type of service provided to a member in one week except for crisis intervention, as described below.(1) In a crisis, as defined in 130 CMR 433.429(K), the MassHealth agency will pay a physician for extra sessions. The physician must bill for these services using the service code for crisis intervention and must document the following in the member's record: (a) the member is in a state of marked life change or crisis;(b) the member's ability to function is likely to deteriorate; and(c) the plan of treatment is to resume or to initiate regular weekly sessions after the resolution of the crisis.(2) Although prior authorization is still required after 17 treatment sessions, the MassHealth agency will pay a physician for more than one type of service provided to a member in one week if the additional service or services are medically necessary. The member's record must document the circumstances necessitating the provision of more than one type of service. The record must make clear that the substitution of one type of service for another would not adequately benefit the member and that an additional type of service is necessary.Amended by Mass Register Issue S1345, eff. 8/11/2017.Amended by Mass Register Issue 1461, eff. 1/21/2022.