130 C.M.R. 438.421 – Denial of Services and Administrative Review | Midpage

Collections
Code of Massachusetts Regulations (CMR)

Chapter 438.000

§ 438.421

130 C.M.R. 438.421

Denial of Services and Administrative Review

Effective Aug 30, 2024M.G.L. c. 118E, s. 7 M.G.L. c. 118E, s. 12MassHealth

(A) A failure or refusal by a CSN agency to furnish services that have been ordered by the member's attending physician or ordering non-physician practitioner and are within the range of payable services, constitutes a violation of 130 CMR 438.000 for which administrative sanctions may be imposed, with the exception of instances where the CSN agency does not have nursing availability to provide services.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-26

Provider Manual Series (130 CMR 438.000)

Transmittal Letter Date

Continuous Skilled Nursing Agency

Manual

CSN-7 08/30/24

(B) When a CSN agency believes that services ordered by the attending physician or ordering non-physician practitioner are not payable under 130 CMR 438.000, the CSN agency must refer the matter to the MassHealth agency for a payment decision. If and to the extent the MassHealth agency determines that the ordered services are payable, the CSN agency must provide those services.