101 Mass. Reg. 317.01

Current through Register 1523, June 7, 2024

Section 317.01 - General Provisions

(1)Scope and Purpose. 101 CMR 317.00 governs the payment rates used by all governmental units for medical services provided to publicly aided patients. Rates for services provided to individuals covered by the Workers' Compensation Act, M.G.L. c. 152, are not set forth in 101 CMR 317.00, but are at 114.3 CMR 40.00: Rates for Services under M.G.L. c. 152, Worker's Compensation Act.

(2)Applicable Dates of Service. Rates contained in 101 CMR 317.00 apply for dates of service on or after May 1, 2024, except as otherwise noted.

(3)Coverage.

(a) Payment rates in 101 CMR 317.00 are used to pay for medical services rendered to patients in a private medical office, licensed clinic, hospital, or other inpatient or outpatient facility or department, independent diagnostic testing facility, patient's residence, or other appropriate setting by an individual eligible provider, when an eligible provider bills for the medical services rendered and no other payment method applies.

(b) The rates of payment under 101 CMR 317.00 are full compensation for patient care rendered to publicly aided patients as well as for any related administrative or supervisory duties in connection with patient care. The rates of payment also reimburse all overhead expenses associated with the service provided, without regard to where the care is rendered.

(4)Disclaimer of Authorization of Services. 101 CMR 317.00 is not authorization for or approval of the procedures for which rates are determined pursuant to 101 CMR 317.00. Governmental units that purchase care are responsible for the definition, authorization, coverage policies, and approval of care and services provided to publicly aided patients.

(5)Coding Updates and Corrections. EOHHS may publish procedure code updates and corrections in the form of an administrative bulletin. Updates may reference coding systems including, but not limited to, the American Medical Association's Current Procedural Terminology (CPT).

(a) The publication of such updates and corrections will list

1. codes for which the code numbers change, with the corresponding cross references between the new codes and the codes being replaced. Rates for such updated codes are set at the rate of the code that is being replaced;

2. deleted codes for which there are no corresponding new codes; and

3. codes for entirely new services that require pricing. EOHHS will list these codes and apply Individual Consideration (I.C.) reimbursement for these codes until appropriate rates can be developed.

(b) For entirely new codes that require new pricing and have Medicare assigned relative value units (RVUs) (or, for applicable services, Medicare rates), EOHHS may list these codes and price them according to the rate methodology used in setting physician rates. When Medicare RVU s (or, for applicable services, Medicare rates) are not available, EOHHS may apply Individual Consideration in reimbursing for these new codes until appropriate rates can be developed.

(6)Administrative Bulletins. EOHHS may issue Administrative Bulletins to add, delete, or otherwise update codes or modifiers, and to clarify its policy on and understanding of substantive provisions of 101 CMR 317.00. EOHHS may also issue Administrative Bulletins to clarify to which duly licensed or certified health care professionals or students the rate methods in this regulation apply, including in the event that the Department of Public Health issues an Order pursuant to M.G.L. c. 94C, and 105 CMR 700.003(H).