130 CMR, § 450.271 - Individual Consideration

(A) The MassHealth agency may identify certain services as requiring individual consideration (I.C.) in program regulations, associated lists of service codes and service descriptions, billing instructions, provider bulletins, and other written issuances from the MassHealth agency. For services requiring individual consideration, the MassHealth agency establishes the appropriate amount of payment based on the standards and criteria set forth in 130 CMR 450.271(B). Providers claiming payment for any I.C .-designated service must submit with such claim a report that includes a detailed description of the service, and is accompanied by supporting documentation that must minimally include where applicable, but is not limited to, an operative report, pathology report, or in the case of a purchase, a copy of the supplier's invoice. The MassHealth agency does not pay claims for "I.C." services unless it is satisfied that the report and documentation submitted by the provider are adequate to support the claim.

(B) The MassHealth agency determines the appropriate payment for an I.C. service in accordance with the following standards and criteria:

(1) the amount of time required to perform the service;

(2) the degree of skill required to perform the service;

(3) the severity and complexity of the member's disease, disorder, or disability;

(4) any applicable relative-value studies; and

(5) any complications or other circumstances that the MassHealth agency deems relevant.

Notes

130 CMR, § 450.271

Amended by Mass Register Issue 1341, eff. 6/16/2017.