101 CMR, § 320.01

Current through Register 1529, August 30, 2024

Section 320.01 - General Provisions

(1)Scope and Purpose. 101 CMR 320.00 governs the payment rates for clinical laboratory services rendered to publicly aided individuals. The rates set forth in 101 CMR 320.00 do not apply to individuals covered by M.G.L. c. 152 (the Workers' Compensation Act). Rates for services rendered to such individuals are set forth in 114.3 CMR 40.00: Rates for Services under M.G.L. c. 152, Workers' Compensation Act.

(2)Applicable Dates of Service. Rates contained in 101 CMR 320.00 apply for dates of service provided on or after September 1, 2024.

(3)Coverage. The payment rates in 101 CMR 320.00 are full compensation for clinical laboratory services rendered to publicly aided individuals.

(4)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). The publication of such updates and corrections lists

(a) codes for which only the code numbers changed, with the corresponding cross-references between existing and new codes;

(b) deleted codes for which there are no corresponding new codes; and

(c) codes for entirely new services that require pricing. EOHHS may list and price these codes according to the rate methodology used in setting clinical laboratory rates when Medicare fees are available (including, for codes relating to Coronavirus Disease 2019 (COVID-19), at 100% of Medicare fees). When Medicare fees are not available, EOHHS may apply individual consideration (I.C.) in reimbursing for these codes until appropriate rates can be developed.

(5)Administrative Bulletins. EOHHS may issue administrative bulletins to:

(a) clarify its policy on and understanding of substantive provisions of 101 CMR 320.00;

(b) specify any clinical laboratory services subject to selective, volume purchase, preferred supplier, or preferred provider contract(s) between a vendor or provider and governmental unit(s), the governmental unit(s) and eligible vendor(s) or provider(s) subject to the contract; the duration of the contract, the prices at which such clinical laboratory services will be available to eligible providers (as defined by the contract, if applicable), the rates which eligible providers (as defined by the contract) will be paid by the relevant governmental unit(s) for such clinical laboratory services, and any other information deemed necessary by EOHHS;

(c) specify any clinical laboratory services subject to rebate agreement(s) between a manufacturer and governmental unit(s), the governmental unit(s) and eligible providers subject to the agreement, the duration of the rebate agreement, the rates which will be paid to eligible providers (as defined by the applicable rebate agreement) by the relevant governmental unit(s) for the specified clinical laboratory services, and any other information deemed necessary by EOHHS.

(6)Disclaimer of Authorization of Services. 101 CMR 320.00 is neither authorization for nor approval of the substantive services for which rates are determined pursuant to 101 CMR 320.00. governmental units that purchase care are responsible for the definition, authorization, and approval of care and services extended to publicly aided individuals.