130 CMR, § 419.431 - Noncoverage
The following are considered non-covered days and are ineligible for payment under 130 CMR 419.000.
(A) Any portion of a day outside the approved
rate structure described in 101 CMR 348.00: Rates for Day Habilitation
Services, during which the member is not receiving scheduled services
from the DH provider, unless the provider documents that the member was
receiving services from the DH provider's staff in a community
setting.
(B) DH provided to a
member when the member's needs can no longer be met by the DH as determined by
the PCP and the professional interdisciplinary team in consultation, or by a
qualified representative of the MassHealth agency, DDS, or DPH.
(C) Days or portion(s) of a day outside of
the rate structure in 101 CMR 348.00: Rates for Day Habilitation
Services on which the following services are provided:
(1) vocational- and prevocational-training
services, which include vocational-skills assessment, career counseling, job
training, and job placement;
(2)
work-related services, which provide participants with work skills and
supervised employment for the production of saleable goods;
(3) educational services, which involve
traditional classroom instruction of academic subjects, tutoring, and academic
counseling; and
(4) social,
vocational, and recreational services not administered through the DH
provider.
(D) DH provided
to members residing in ICF/ID.
(E)
DH provided more than five days per week and six hours per day per
member;
(F) DH provided at a site
that has not been approved by the MassHealth agency or its designee or does not
have a current approval on file;
(G) DH provided on or after the effective
date of the discharge plan; and
(H)
Claims billed above the census on file as approved by the MassHealth agency or
its designee.
Notes
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