1. (A) All inpatient services must be provided in accordance with 130 CMR 450.204: Medical Necessity or 130 CMR 415.415, and are subject, among other things, to utilization review under 130 CMR 450.207: Utilization Management Program for Acute Inpatient Hospital through 130 CMR 450.209: Utilization Management: Prepayments Review for Acute Inpatient Hospitals and to requirements governing overpayments under 130 CMR 450.235(B): Overpayments and 450.237: Overpayment Determination.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-6b

Provider Manual Series (130 CMR 415.000)

Transmittal Letter Date

Acute Inpatient Hospital Manual

AIH-52 01/02/15

1. (B) (1) The MassHealth agency (or its agent) will review inpatient services provided to members to determine the medical necessity, pursuant to 130 CMR 450.204, or administrative necessity and appropriateness, pursuant to 130 CMR 415.415, of such services. Any such review may be conducted prior to, concurrently, or retrospectively following the member’s inpatient admission. Reviewers consider the medical-record documentation of clinical information available to the admitting provider at the time the decision to admit was made. Reviewers do not deny admissions based on what happened to the member after the admission. However, if an admission was not medically necessary at the time of the decision to admit, but the medical record indicates that an inpatient admission later became medically necessary, the admission will be approved as long as all other MassHealth requirements are met.

   1. (2) If, pursuant to any review, the MassHealth agency concludes that the inpatient admission was not medically or administratively necessary, the MassHealth agency will deny payment for the inpatient admission.
   2. (3) If the MassHealth agency issues a denial notice for an acute inpatient hospital admission pursuant to 130 CMR 415.414 and 450.204: Medical Necessity as well as either 450.209: Utilization Management: Prepayment for Acute Inpatient Hospitals or 450.237: Overpayments: Determination, the hospital may rebill the claim as an outpatient service, as long as the MassHealth agency has determined the service would have been appropriately provided in an outpatient setting. In order for the hospital to receive payment under 130 CMR 415.414(B)(3), the outpatient claim and a copy of the denial notice must be received by the MassHealth agency within 90 days from the date of the denial notice and must comply with all applicable MassHealth requirements.

2. (C) To support the medical necessity of an inpatient admission, the provider must adequately document in the member’s medical record that a provider with applicable expertise expressly determined that the member required services involving a greater intensity of care than could be provided safely and effectively in an outpatient setting. Such a determination may take into account the amount of time the member is expected to require inpatient services, but must not be based solely on this factor. The decision to admit is a medical determination that is based on factors, including but not limited to the:

   1. (1) member’s medical history;
   2. (2) member’s current medical needs;
   3. (3) severity of the signs and symptoms exhibited by the member;
   4. (4) medical predictability of an adverse clinical event occurring with the member;
   5. (5) results of outpatient diagnostic studies;
   6. (6) types of facilities available to inpatients and outpatients; and
   7. (7) MassHealth agency’s Acute Inpatient Hospital Admission Guidelines in Appendix F of the Acute Inpatient Hospital Manual and in various appendices of other appropriate provider manuals. The MassHealth agency has developed such guidelines to help providers determine the medical necessity of an acute inpatient hospital admission. These guidelines indicate when there is generally no medical need for such an admission.
3. (D) If, as the result of any review, the MassHealth agency determines that any hospital inpatient admission, stay, or service provided to a member was not covered under the member’s coverage type (see 130 CMR 450.105: Coverage Types) or was delivered without obtaining a required authorization including, where applicable, authorization from the member’s primary-care provider, the MassHealth agency will not pay for that inpatient admission, stay, or service.

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS

4-7

Provider Manual Series (130 CMR 415.000)

ACUTE INPATIENT HOSPITAL TRANSMITTAL LETTER DATE

MANUAL

IH/AC-27 10/01/93

415.415: Reimbursable Administrative Days

1. (A) Administrative days as defined in 130 CMR 415.402 are reimbursable if the following conditions are met:

   1. (1) the recipient requires an admission to a hospital or a continued stay in a hospital for reasons other than the need for services that can only be provided in an acute inpatient hospital as defined in 130 CMR 415.402 (see 130 CMR 415.415(B) for examples); and
   2. (2) a hospital is making regular efforts to discharge the recipient to the appropriate setting. These efforts must be documented according to the procedures described in 130 CMR 450.205. The regulations covering discharge-planning standards described in 130 CMR 415.419 must be followed, but they do not preclude additional, effective discharge-planning activities.

2. (B) Examples of situations that may require hospital stays at less than a hospital level of care include, but are not limited to, the following.

   1. (1) A recipient is awaiting transfer to a chronic disease hospital, rehabilitation hospital, nursing facility, or any other institutional placement.
   2. (2) A recipient is awaiting arrangement of home services (nursing, home health aide, durable medical equipment, personal care attendant, therapies, or other community-based services).
   3. (3) A recipient is awaiting arrangement of residential, social, psychiatric, or medical services by a public or private agency.
   4. (4) A recipient with lead poisoning is awaiting deleading of his or her residence.
   5. (5) A recipient is awaiting results of a report of abuse or neglect made to any public agency charged with the investigation of such reports. (6)recipient in the custody of the Department of Social Services is awaiting foster care when other temporary living arrangements are unavailable or inappropriate.
   6. (7) A recipient cannot be treated or maintained at home because the primary caregiver is absent due to medical or psychiatric crisis, and a substitute caregiver is not available.

   7. (8) A recipient is awaiting a discharge from the hospital and is receiving skilled nursing or other skilled services. Skilled services include, but are not limited to:

      1. (a) maintenance of tube feedings;
      2. (b) ventilator management;
      3. (c) dressings, irrigations, packing, and other wound treatments;
      4. (d) routine administration of medications;
      5. (e) provision of therapies (respiratory, speech, physical, occupational, etc.);
      6. (f) insertion, irrigation, and replacement of catheters; and
      7. (g) intravenous, intramuscular, or subcutaneous injections, or intravenous feedings (for example, total parenteral nutrition.)

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS

4-8

Provider Manual Series (130 CMR 415.000)

ACUTE INPATIENT HOSPITAL TRANSMITTAL LETTER DATE

MANUAL

IH/AC-27 10/01/93

415.416: Nonreimbursable Administrative Days

Administrative days are not reimbursable when:

1. (A) a hospitalized recipient is awaiting an appropriate placement or services that are currently available but the hospital has not transferred or discharged the recipient because of the hospital's administrative or operational delays;
2. (B) the Division or its agent determines that appropriate noninstitutional or institutional placement or services are available within a reasonable distance of the recipient's noninstitutional (customary) residence and the recipient, the recipient's family, or any person legally responsible for the recipient refuses the placement or services; or
3. (C) the Division or its agent determines that appropriate noninstitutional or institutional placement or services are available within a reasonable distance of the recipient's noninstitutional (customary) residence and advises the hospital of the determination, and the hospital or the physician refuses or neglects to discharge the recipient.

415.417: Notification of Denial, Reconsideration, and Appeals

1. (A) Notification of Denial. The Division or its agent shall notify the recipient, the hospital, and the recipient's attending physician whenever it determines as part of a concurrent review that the hospital admission or stay, or any part thereof, is not medically or administratively necessary. The Division or its agent shall notify the hospital and the recipient's attending physician whenever it determines as part of a concurrent or retrospective review that the hospital stay is or was no longer medically necessary but is or was administratively necessary. The Division or its agent shall notify the hospital and the recipient whenever it determines as part of a concurrent review that a hospital stay is no longer administratively necessary due to the refusal of an appropriate placement.
2. (B) Reconsideration. An agent of the Division under 130 CMR 415.000 may provide an opportunity for reconsideration of a determination made by that agent. If a reconsideration is available, notice of the agent's determination will include written notice of: the right to a reconsideration; the time within and manner in which a reconsideration must be requested; and the time within which a decision will be rendered. A hospital, a physician, or a recipient entitled to have a determination reconsidered must request and have a reconsideration determination given before requesting a hearing under 130 CMR 415.417(C).

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-9

Provider Manual Series (130 CMR 415.000)

Transmittal Letter Date

Acute Inpatient Hospital Manual

AIH-43 12/26/08

1. (C) Appeals to the MassHealth Agency.

   1. (1) A member may request a fair hearing before the MassHealth agency when the MassHealth agency or its agent determines as the result of a concurrent review that a continued stay is not administratively necessary due to the availability of an appropriate placement as described in 130 CMR 415.415.
   2. (2) A hospital may request a fair hearing before the MassHealth agency when the MassHealth agency or its agent determines as the result of a concurrent review that an admission or a continued stay, or any part thereof, is not medically necessary but is administratively necessary.
   3. (3) A member or a hospital may request a fair hearing before the MassHealth agency when the MassHealth agency or its agent determines as the result of a concurrent review that an admission or continued stay, or any part thereof, is not medically or administratively necessary.
   4. (4) Written notice of the right to a fair hearing and the manner in which and time within which a hearing must be requested will be provided at the time of the initial determination or of the reconsideration decision by the MassHealth agency or its agent.
   5. (5) A hospital may appeal the determination of the MassHealth agency or its agent as the result of a retrospective review that an admission or a continued stay, or any part thereof, was not medically necessary, was not administratively necessary, or was not medically necessary but was administratively necessary. These appeals are governed by 130 CMR 450.000.

415.418: Accident Victims

When a member is admitted to an acute inpatient hospital as the result of an accident, it is the hospital's responsibility to notify the member's local office so that assignment may be taken of the member's right to third-party coverage of claims or possible recovery of claims as the result of tort action.

415.419: Discharge-Planning Standards

1. (A) Staff.

   1. (1) The hospital must assign in writing the responsibility for all patient discharge planning to one appropriate department (such as social services or continuing care). That department in turn must designate specific staff members whose primary duties are discharge planning.
   2. (2) The discharge-planning staff must include either a registered nurse or a social worker who is licensed or eligible and applying for licensure in Massachusetts, and is under the supervision of, or in consultation with, a licensed graduate-level nurse or social worker.
   3. (3) Unless permitted a lower ratio by the MassHealth agency, the hospital must employ one discharge planner or full-time equivalent for every 60 licensed beds, excluding maternity and special-care units. Visiting Nurse Association (VNA) or home health staff who are not employed by the hospital, but who regularly perform discharge-planning activities there, may be included in this ratio.
   4. (4) The hospital must demonstrate to the MassHealth agency that it provides formal inservice training programs and regular case conferences for all discharge-planning staff and all other personnel who affect the discharge-planning process.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-10

Provider Manual Series (130 CMR 415.000)

Transmittal Letter Date

Acute Inpatient Hospital Manual

AIH-43 12/26/08

1. (B) Operations and Procedures.

   1. (1) The discharge-planning staff must maintain a chronological list, updated daily, of all members on administrative day status. The list must contain the date administrative day status commenced and a recommendation for institutional or noninstitutional care upon discharge based on nursing facility medical eligibility criteria. The discharge-planning department must use this chronological list to ensure that members who have spent the longest time on administrative day status receive priority in placement attempts.

   2. (2) The discharge-planning department must maintain up-to-date lists of the following:

      1. (a) all licensed nursing facilities within a 25-mile minimum radius of the hospital. This list must show, for each facility, the number of beds, whether the facility is Medicare certified, whether the facility is Medicaid certified, any other notable characteristics (for example, the availability of bilingual staff), and the name of the individual who is responsible for admissions; and
      2. (b) all community-based organizations and resources within a 25-mile minimum radius of the hospital that provide services and support to members discharged to the community. Such resources include, but are not limited to, housing for the elderly, home health agencies, homemaker services, transportation services, friendly visitor programs, and meal programs.
   3. (3) As a routine practice, admissions data, including but not limited to age and diagnosis, must be screened by discharge-planning staff within 24 hours of admission in accordance with written criteria that identify pertinent patient characteristics and any high-risk diagnoses. Discharge-planning activities must then commence within 72 working hours of admission for every member expected to require posthospital care or services. Admissions data must be noted in the member's record in the discharge-planning department. The written criteria used to screen members must be available to the MassHealth agency.
   4. (4) The hospital must ensure that a clinician, certified in accordance with 130 CMR 415.420, completes a CANS during the discharge planning process for those members under the age of 21 who are receiving services in a DMH-licensed bed.
   5. (5) The hospital must have a written policy that allows discharge-planning staff access to all members and their medical records. If such access is medically contraindicated, the member's physician must sign a statement specifying the reason for the contraindication and the hospital must maintain the statement in the member's medical or discharge-planning record.
   6. (6) The discharge-planning staff and the primary-care team must coordinate and document in writing a plan for each member who requires posthospital care that specifies the services or care expected to be required by the member, the frequency, intensity, and duration of such services, and the resources available to provide the care or services, including available family and community support. The plan must be updated if the member's condition changes significantly. If an institutional placement for the member is recommended upon discharge, the plan must state why available community resources are inadequate to meet the member's needs.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-11

Provider Manual Series (130 CMR 415.000)

Transmittal Letter Date

Acute Inpatient Hospital Manual

AIH-43 12/26/08

1. (7) Each visit to a member by a member of the discharge-planning staff must be noted in the member's discharge-planning record. The notation must include the date of the meeting, any discharge options discussed, any particular problems noted, any agreements reached with the member, and the future activities of the discharge-planning staff to address the problems raised or to continue preparation of the member for discharge.
2. (8) Whenever possible, the discharge-planning staff or primary-care team must contact the member's family to encourage its involvement in planning the member's discharge. To this end, family members must be informed of the discharge options and community resources available to the member and provided with lists of nursing facilities and community resources in the area. When possible, these meetings or telephone consultations with the family must be held once every two weeks until the member is discharged. The dates of these meetings and other contacts with family, matters discussed, problems identified, and agreements reached must be entered on the member's discharge-planning record.

3. (9) The hospital must have written procedures for arranging posthospital services for members. At a minimum, these procedures must include frequent, systematic contacts (usually, three times weekly) by telephone or in person to all nursing facilities and community-service providers within a 25-mile minimum radius of the hospital in order to

   1. (a) determine what services at that location are or will soon become available and to ensure that the provider has current information, including medical and psychosocial status, on any member now or soon needing placement; and
   2. (b) arrange for placement or services or both for members awaiting discharge. These member-specific contacts must be documented as to their number, frequency, and outcome, and must be made by a registered nurse or by a social worker who is licensed or eligible and applying for licensure in Massachusetts. The only exception in which such a call may be made by another person is when that person regularly works in the discharge-planning department, has received training in patient placement from a discharge planner, and consults all the relevant discharge documentation for the member when making the call. If, during the call, a question is asked that cannot be answered from the written data, it must be referred to a discharge planner.

4. (C) Nursing Facility Medical Eligibility Criteria.

   1. (1) The member's physician and a registered nurse must determine eligibility for institutional or noninstitutional care required by a member upon discharge in accordance with MassHealth nursing facility medical eligibility criteria. Both the member's medical and discharge-planning records must include the specific factors that indicate the recommended care and the names of the persons who determined it.
   2. (2) For any member on administrative day status, the recommended care must be reassessed at least once every two weeks and whenever a significant change occurs in the member's medical or psychosocial condition. The date of each reassessment and the name of the person or persons making the reassessment must be noted in both the member's medical and discharge-planning records.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-12

Provider Manual Series (130 CMR 415.000)

Transmittal Letter Date

Acute Inpatient Hospital Manual

AIH-43 12/26/08

1. (D) Cooperation with Long-Term-Care Preadmission Screening Program. In areas of the state where the MassHealth agency or its agent administers a preadmission screening program for long-term-care medical eligibility, the hospital must forward all required documentation to the MassHealth agency or its agent and must request long-term-care medical eligibility authorization before the member may be discharged. The hospital may seek the assistance of the MassHealth agency or its agent in finding placements for members on administrative day status. For those members on administrative day status, the hospital must allow the MassHealth agency or its agent access to the medical record.
2. (E) Reporting Discrimination Against Members. The hospital must have a formal written policy for the discharge-planning staff to use when reporting to the MassHealth agency all suspected cases of discrimination against members by MassHealth providers.
3. (F) Recordkeeping Requirements. The hospital must maintain a record of administrative days for four years. The hospital must maintain copies of the CANS completed in accordance with 130 CMR 415.419(B)(4) in the member’s medical record.
4. (G) Disclosure Requirements. All written procedures and policies, lists, review criteria, discharge plans, and records used by the discharge-planning department in performing its duties must be made available for inspection by the MassHealth agency.

415.420: Child and Adolescent Needs and Strengths (CANS) Certification

The following clinicians are eligible to administer the Child and Adolescent Needs and

Strengths (CANS) in acute inpatient hospitals and must be certified every two years according to the process established by the Executive Office of Health and Human Services (EOHHS):

1. (A) psychiatrists and psychiatric residents;
2. (B) psychiatric nurse mental-health clinical specialists;
3. (C) psychologists who have a specialization in clinical or counseling psychology;
4. (D) social workers who have a master’s degree in social work from an accredited educational

institution; and

1. (E) counselors who have a master’s degree in counseling education, counseling psychology, or

rehabilitation psychology from an accredited educational institution.

415.421: Child and Adolescent Needs and Strengths (CANS) Data Reporting

For each Child and Adolescent Needs and Strengths (CANS) conducted, the hospital must

report data collected during the assessment to the MassHealth agency, in the manner and format specified by the MassHealth agency.

(130 CMR 415.422 through 415.424 Reserved)

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS

4-13

Provider Manual Series (130 CMR 415.000)

ACUTE INPATIENT HOSPITAL TRANSMITTAL LETTER DATE

MANUAL

AIH-37 07/01/00

415.425: Medical Leave of Absence: Responsibilities of the Hospital for the Transfer of a Member Who Is a

Resident of a Nursing Facility

1. (A) Effective for dates of service on or after July 1, 2000, the Division will pay a nursing facility to reserve a bed during a member’s medical leave of absence in accordance with the terms and conditions of 130 CMR 415.425.

2. (B) Whenever a member is admitted to a hospital from a nursing facility, the hospital must comply with the following requirements.

   1. (1) Not later than the second working day of the member 's hospital stay, the hospital must:

      1. (a) review the member 's medical record to determine the member 's estimated length of stay; and
      2. (b) notify the nursing facility by telephone of the estimated number of days of the stay and document in the member 's medical record the date of such telephone notification to the nursing facility.
   2. (2) When the member's estimated length of stay will be 20 consecutive days or less, the facility must reserve a bed for the same number of days and the hospital must so notify its discharge- planning unit.
   3. (3) When the member's estimated length of stay exceeds 20 consecutive days, the facility must not reserve a bed and the hospital must so notify its discharge-planning unit.

3. (C) The hospital must review the member 's medical status on an ongoing basis. Whenever a change in the member 's medical status occurs before the 20th day of the hospital stay, the hospital must:

   1. (1) review the member's medical record;
   2. (2) revise the estimated length of stay if the member's change in medical status so requires; and
   3. (3) immediately notify the nursing facility by telephone of the revised estimated length of stay, in accordance with 130 CMR 415.425(B).

4. (D) If the member is transferred within the 20-day medical leave-of-absence period to another hospital:

   1. (1) the transferring hospital must notify the nursing facility immediately by telephone; and
   2. (2) the receiving hospital must comply with all the requirements stated in 130 CMR 415.425.

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS

4-14

Provider Manual Series (130 CMR 415.000)

ACUTE INPATIENT HOSPITAL TRANSMITTAL LETTER DATE

MANUAL

AIH-37 07/01/00

1. (E) If the member is transferred within the 20-day medical leave-of-absence period to another nursing facility or noninstitutional setting, or if the member dies, the hospital must notify the original nursing facility immediately by telephone.
2. (F) Failure by the hospital to comply with any of the requirements set forth in 130 CMR 415.425 may result in administrative fines, in accordance with the Division's administrative and billing regulations at 130 CMR 450.237 and 450.238.

REGULATORY AUTHORITY

130 CMR 415.000: M.G.L. c. 18, § 10; M.G.L. c. 118E, § 4.