130 CMR 450.204 - Medical Necessity
The MassHealth agency does not pay a provider for services that are not medically necessary and may impose sanctions on a provider for providing or prescribing a service or for admitting a member to an inpatient facility where such service or admission is not medically necessary.
(A) A service is medically necessary if
(1) it is reasonably calculated to prevent,
diagnose, prevent the worsening of, alleviate, correct, or cure conditions in
the member that endanger life, cause suffering or pain, cause physical
deformity or malfunction, threaten to cause or to aggravate a handicap, or
result in illness or infirmity; and
(2) there is no other medical service or site
of service, comparable in effect, available, and suitable for the member
requesting the service, that is more conservative or less costly to the
MassHealth agency. Services that are less costly to the MassHealth agency
include, but are not limited to, health care reasonably known by the provider,
or identified by the MassHealth agency pursuant to a prior-authorization
request, to be available to the member through sources described in
130
CMR 450.317(C),
503.007:
Potential Sources of Health Care, or 517.007:
Utilization of Potential Benefits.
(B) Medically necessary services must be of a
quality that meets professionally recognized standards of health care, and must
be substantiated by records including evidence of such medical necessity and
quality. A provider must make those records, including medical records,
available to the MassHealth agency upon request. (See
42 U.S.C.
1396a(a)(30) and 42 CFR
440.230 and 440.260.)
(C) A
provider's opinion or clinical determination that a service is not medically
necessary does not constitute an action by the MassHealth agency.
(D) Additional requirements about the medical
necessity of MassHealth services are contained in other MassHealth regulations
and medical necessity and coverage guidelines.
(E) Any regulatory or contractual exclusion
from payment of experimental or unproven services refers to any service for
which there is insufficient authoritative evidence that such service is
reasonably calculated to have the effect described in 130 CMR
450.204(A)(1).
Notes
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