Section 613.03 - Eligible Services Requirements(1)General. To qualify as a service eligible for payment, the service must meet the following criteria. (a)Eligible Services Categories. There are three categories of services eligible for payment from the Health Safety Net, as follows: 1. Reimbursable Health Services to Low Income Patients as defined in 101 CMR 613.04;2. Medical Hardship, pursuant to the requirements in 101 CMR 613.05; and3. Bad Debt, pursuant to the requirements in 101 CMR 613.06.(b)Eligible Services Limitations - General. The Health Safety Net does not pay for, and Providers may not submit claims to the Office for, services that are not medically necessary or for which another public or private payer is responsible. The Health Safety Net is the payer of last resort. 1. The Health Safety Net Office may request, and the Provider must provide, any and all medical records (or clear photocopies of such records) corresponding to or documenting the services claimed upon request of the Health Safety Net Office or its agent.2. The medical record must contain sufficient data to document fully the nature, extent, quality, and necessity of the care provided to a Patient for each service claimed for payment.3. For services for which MassHealth requires prior authorization, the Provider must ensure that current clinical standards are used to determine whether the service is medically necessary. The Health Safety Net Office or its agent may audit claims to verify medical necessity.4. All Providers must make diligent efforts to obtain payment first from other resources, including personal injury protection (PIP) payments, to ensure that the Health Safety Net is the payer of last resort.5. If the Health Safety Net Office, or its agent, identifies a third-party resource after the Provider has billed and received payment from the Health Safety Net, it will notify the Provider of this available third-party resource. Upon receipt of notification, the Provider must remit the Health Safety Net payment or provide documentation of diligent efforts as described in 101 CMR 613.03(1)(c)3. to obtain payment from the third-party resource. The Office, or its agent, will review the submitted documentation to determine whether the Provider made diligent efforts. If the Office, or its agent, determines the Provider did not make diligent efforts to receive payment from the third party, the Health Safety Net may recover the payment by deducting it from future payments.6. If the Office, or its agent, identifies a third-party resource, the Office may recover from the financially responsible third party the costs attributable to services provided to an individual that were paid by the Health Safety Net. A payment from the Health Safety Net for such services is recoverable from the third party and the payment, after notice to the third party, operates as a lien under M.G.L. c. 118E.(c)Reimbursable Health Services Limitations - Low Income Patients.1. For insured Low Income Patients, the Health Safety Net does not pay for, and Providers may not submit claims for, services for which the primary insurer has denied payment because of a technical billing error, because the Patient obtained out of network services, because the Patient failed to obtain required prior authorization for services, or because of other administrative reasons. The Health Safety Net does not pay claims for the balance of an insurer's contractual allowance or for late charges for a service that has been paid by another payer.2. For insured Low Income Patients with other available resources including, but not limited to, private health and casualty insurance, the Health Safety Net a. does not pay a Provider if it determines that, among other things, the Provider has not made diligent efforts to obtain payment from those resources; andb. recovers any payments made if it determines that the Provider has not made diligent efforts to obtain payment from those resources.3. "Diligent efforts" is defined as making every effort to identify and obtain payment from all other liable parties, including insurers. Diligent efforts include, but are not limited to a. determining the existence of insurance that could pay for medical expenses by asking the Patient if he or she has other insurance and by using insurance databases available to the Provider. In the event of a motor vehicle accident, this includes investigating whether the Patient, driver, and/or owner of any motor vehicle involved had a motor vehicle liability policy;b. verifying the Patient's other health insurance coverage, currently known to the Health Safety Net, through EVS, or any other health insurance resource available to the Provider, on each date of service and at the time of billing;c. submitting claims to all insurers with the insurer's designated service code for the service provided;d. complying with the insurer's billing and authorization requirements;e. appealing a denied claim when the service is payable in whole or in part by an insurer; andf. immediately returning any payment received from the Office when any available third-party resource has been identified.4. For insured Low Income Patients with private insurance, including Student Health Plans and Qualified Health Plans other than the Premium Assistance Payment Program Operated by the Health Connector, the Health Safety Net pays only for deductibles, coinsurance, and Reimbursable Health Services not covered by the insurer. The Health Safety Net does not pay for copayments required by a private insurer.5. For MassHealth members enrolled in MassHealth Limited, EAEDC, CMSP, CMSP plus Limited, and for MassHealth Family Assistance - Children, the Health Safety Net pays only for Reimbursable Health Services not covered by the member's MassHealth benefit. A Provider may submit a claim for Reimbursable Health Services not covered by EAEDC only if the member's EAEDC eligibility is non-temporary. A Provider may submit a claim for Reimbursable Health Services not covered by CMSP only if the individual's MAGI income is less than or equal to 300% of the FPL.6. For MassHealth members enrolled in MassHealth Standard, MassHealth CarePlus, CommonHealth, and Family Assistance, excluding MassHealth Family Assistance -Children, the Health Safety Net pays only for Adult Dental Services provided by a Community Health Center, Hospital Licensed Health Center, or other Satellite Clinic that are not covered by MassHealth.7. For MassHealth members, the Health Safety Net does not pay for, and Providers may not submit, claims to the Office for MassHealth copayments.8. For Low Income Patients enrolled in Medicare (including Medicare Advantage), including MassHealth members eligible for Medicare Buy-In and Senior Buy-In, the Health Safety Net pays for Reimbursable Health Services not covered by the patient's insurance, and for copayments, coinsurance, and deductibles required by the patient's insurance.9. The Health Safety Net does not pay copayments for the Premium Assistance Payment Program Operated by the Health Connector.10. The Health Safety Net pays for Reimbursable Health Services provided to Low Income Patients for services provided during the Eligibility Period specified in 101 CMR 613.04(7).(d)Eligible Services Limitations - Serious Reportable Events. The Health Safety Net does not pay for services directly related to a Serious Reportable Event (SRE) as defined in 105 CMR 130.332(A): Definitions Applicable to 105 CMR 130.332. 1. A Provider must not charge, bill, or otherwise seek payment from the Health Safety Net, a Patient, or any other payer as required by 105 CMR 130.332: Serious Reportable Events (SREs) and Serious Adverse Drug Events (SADE), for services provided as a result of an SRE occurring on premises covered by a Provider's license, if the Provider determines that the SRE was b. within the Provider's control; andc. unambiguously the result of a system failure as required by 105 CMR 130.332(B): Reporting of SREs and (C): Preventability Determination.2. A Provider must not charge, bill, or otherwise seek payment from the Health Safety Net, a Patient, or any other payer as required by 105 CMR 130.332: Serious Reportable Events (SREs) and Serious Adverse Drug Events (SADE) for services directly related to a. the occurrence of the SRE;b. the correction or remediation of the event; orc. subsequent complications arising from the event as determined by the Health Safety Net Office on a case-by-case basis.3. A Provider may submit a claim for services it provides that result from an SRE that did not occur on its premises only if the treating facility and the facility responsible for the SRE do not have common ownership or a common corporate parent.4. Readmissions to the same hospital or follow-up care provided by the same Provider or a Provider owned by the same parent organization are not billable if the services are associated with the SRE as described in 101 CMR 613.03(1)(d)2.(2)Reimbursable Health Services.(a)General. The Health Safety Net pays only for the Reimbursable Health Services listed below. Providers may submit claims only for Reimbursable Health Services provided by Acute Hospitals and Community Health Centers in accordance with the MassHealth Standard program using the payment codes as listed in Subchapter 6 of the MassHealth Inpatient and Outpatient Provider Manuals and other MassHealth Provider manuals, unless otherwise specified in 101 CMR 614.00: Health Safety Net Payments and Funding. The Health Safety Net Office may add additional codes and Reimbursable Health Services by administrative bulletin, as described in 101 CMR 613.08(4).(b)Pharmacy. 1. The Health Safety Net pays only for prescribed drugs according to the coverage rules, including 130 CMR 406.411: Prescription Requirements; 130 CMR 406.412(A): Drugs and (B)(1); 130 CMR 406.413: Limitations on the Coverage of Drugs; and 130 CMR 406.422: Prior Authorization, established by MassHealth and processed through POPS. Providers may not submit claims for drugs excluded from the MassHealth Drug List.2. Notwithstanding 101 CMR 613.03(2)(b)1., the Health Safety Net may pay for prescribed drugs designated by the MassHealth agency as excluded from coverage for MassHealth members through the 340B Drug Pricing Program pursuant to 130 CMR 406.404(D)(1): Notification of Participation.(c)340B Pharmacies. 1. A 340B Provider may submit a Health Safety Net claim only for outpatient pharmacy services provided through the Provider's 340B pharmacy unless the claim is submitted by a Provider that directly operates both a 340B pharmacy and a retail pharmacy and the claim is for a drug provided to an individual who cannot be seen by a Provider-based prescriber to obtain a prescription within a clinically appropriate time period. The Provider must inform the Patient that it may not fill future prescriptions unless the individual becomes a Patient of the Provider or is placed on a waiting list in the instance that the Provider is not accepting new patients. A Provider may submit a Health Safety Net claim only for the dispensing fee for covered prescribed drugs provided to Low Income Patients if that individual is using a pharmaceutical company sponsored free drug program and the drug is dispensed by the pharmacy. A Provider may not submit a Health Safety Net claim for free or donated prescribed drugs where the drugs are stored and dispensed from a site other than the pharmacy (e.g., secured closet near exam room).2. A 340B Provider must provide the Health Safety Net Office 90 days' advance written notice of its intent to discontinue providing prescribed drugs to Low Income Patients or submitting claims to the Health Safety Net for outpatient pharmacy services pursuant to 101 CMR 613.03(2)(c)1.(d)Utilization Review. The Health Safety Net Office conducts a utilization review program designed to monitor the appropriateness of services for which payments are made and to promote the delivery of care in the most appropriate setting.(e)Noncovered Services. The Health Safety Net does not pay for any of the following services: nonmedical services, such as social, educational, and vocational services; cosmetic surgery; canceled or missed appointments; telephone conversations or consultations; court testimony; research or the provision of experimental, cosmetic, unproven, or otherwise medically unnecessary procedures or treatments; the provision of whole blood except for the administrative and processing costs associated with the provision of blood and its derivatives; the treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment; however, the Health Safety Net pays for the diagnosis of male and female infertility); vocational rehabilitation services; sheltered workshops; recreational services; life-enrichment services; alcohol or drug drop-in centers; drugs used for the treatment of obesity; cough and cold preparations; drugs related to the treatment of male or female infertility; absorptive lenses of greater than 25% absorption; photochromatic lenses, sunglasses, or fashion tints; treatment of congenital dyslexia; extended-wear contact lenses; invisible bifocals; and the Welsh 4-Drop Lens.(3)Reimbursable Health Services - Acute Hospitals. (a) The Health Safety Net pays Acute Hospitals only for the Reimbursable Health Services listed in 101 CMR 613.03(3)(a)1. through 34.1.Abortion Services. The Health Safety Net pays for abortion services performed in accordance with the applicable provisions of 130 CMR 410.434: Abortion Services: Reimbursable Services.2.Administrative Days. The Health Safety Net pays for Administrative Days meeting the requirements set forth in 130 CMR 415.415: Reimbursable Administrative Days and 130 CMR 415.416: Nonreimbursable Administrative Days.3.Ambulatory Surgery Services.6.Dental Services. The Health Safety Net pays only for dental services identified in Subchapter 6 of the MassHealth Dental Manual and for Adult Dental Services not covered by MassHealth. Certain dental services may be subject to prior authorization, as specified by the Health Safety Net Office in billing instructions, administrative bulletins, or other written issuances.7.Durable Medical Equipment. The Health Safety Net pays only for crutches and canes provided during a Hospital Visit.8.Family Planning Services.9.Hearing Instrument Services.10.Inpatient Hospice Services.12.Inpatient Psychiatric. The Health Safety Net pays only for services provided in a Medicare certified psychiatric unit.13.Laboratory Services. The Health Safety Net does not pay separately for routine specimen collection and preparation for the purpose of clinical laboratory analysis. Specimen collection and preparation is considered part of the laboratory service.14.Medical Supplies. The Health Safety Net pays for medical supplies used in the delivery of inpatient and outpatient care. It also pays for spacers used with metered dose inhalers, nebulizers, diabetic supplies, home glucose monitors, and portable peak flow monitors.15.Mental Health Services. The Health Safety Net pays for mental health services except for noncovered services in 101 CMR 613.03(2)(e). The Health Safety Net pays only for mental health services that meet the requirements in the MassHealth Acute Outpatient Hospital Manual at 130 CMR 410.471: Mental Health Services: Introduction through 130 CMR 410.475: Mental Health Services: Staffing Requirements, and 130 CMR 410.479(A): Provision of Services.16.Nurse Midwife Services.17.Nurse Practitioner Services.18.Observation Services. Outpatient hospital services provided anywhere in an Acute Hospital, to evaluate a Patient's medical condition and determine the need for an inpatient admission. Observation services are provided under order of a physician, consist of the use of a bed and intermittent monitoring by professional licensed clinical staff, and may be provided for more than 24 hours.20.Outpatient Services. Outpatient services are services provided by Acute Hospital outpatient departments and by Hospital Licensed Health Centers or other Satellite Clinics. Such services include, but are not limited to, Emergency Services, Primary or Elective Care, observation services, Ancillary Services, and day-surgery services.21.Outpatient Psychiatric Services.23.Physician Services. The Health Safety Net pays only for services provided at Acute Hospital sites by Acute Hospital-based physicians who are employed or contracted by the Acute Hospital and who receive payment from the Acute Hospital for their services.27.Rehabilitation Services. For inpatient rehabilitation, the Health Safety Net pays only for services provided in a Medicare certified rehabilitation unit.28.Renal Dialysis Services.29.Speech and Hearing Services.30.Sterilization Services.31.Substance Use Disorder Services, including methadone treatment as described in 130 CMR 418.000: Substance Use Disorder Treatment Services, except for noncovered services in 101 CMR 613.03(2)(e).32.Therapy Services. The Health Safety Net pays only for therapy services as defined in the MassHealth Acute Outpatient Hospital Manual, at 130 CMR 410.451(A) and (B). Before therapy is initiated, there must be a comprehensive evaluation of the Patient's medical condition, disability, and level of functioning to determine the need for treatment and, when treatment is indicated, to develop a treatment plan.33.Tobacco Cessation. The Health Safety Net pays only for services as defined by Subchapter 6 of the MassHealth Acute Hospital Outpatient Manual.34.Vision Care Services. The Health Safety Net pays only for services as defined in 130 CMR 410.481: Vision Care Services.(4)Reimbursable Health Services - Community Health Centers.(a)General. Community Health Centers may submit claims only for Reimbursable Health Services set forth in 101 CMR 613.03(4)(b). The Reimbursable Health Services must meet the requirements set forth in 101 CMR 613.03(4)(c).1. Community Health Centers may submit claims only for services provided under the Community Health Center's clinic license.2. A Community Health Center may submit claims only for Reimbursable Health Services provided on site, except for off-site 340B Pharmacy Services and certain Evaluation and Management visits provided to the Community Health Center's Patients at an Acute Hospital. A Community Health Center may submit claims for dentures provided on site but manufactured or repaired at an off-site contractor.3. The Health Safety Net does not pay Community Health Centers for performing, administering, or dispensing experimental, cosmetic, unproven, or otherwise medically unnecessary procedures or treatments or treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment); however, the Health Safety Net pays for the diagnosis of male and female infertility.(b)Reimbursable Health Services.1.Audiology Services. The Health Safety Net pays for audiology services if the services were provided at the written request of a physician, nurse practitioner, or physician assistant who has found some indication of a hearing problem. Documentation of the request and of the hearing problem must be kept in the Patient's medical record. 2. Behavioral Health Services.3.Cardiovascular and Pulmonary Diagnostic Services.4.Dental Services. The Health Safety Net pays for dental services identified in Subchapter 6 of the MassHealth Dental Manual and for Adult Dental Services not covered by MassHealth. Certain dental services may be subject to prior authorization, as specified by the Health Safety Net Office in billing instructions, administrative bulletins, or other written issuances.5.Diabetes Self-management Training. The Health Safety Net pays for diabetes self-management training services as defined by Subchapter 6 of the MassHealth Community Health Center Manual.6.Electrocardiogram (EKG) Services. The Health Safety Net pays for EKG services only when the service is provided at the written request of a Community Health Center staff physician who will interpret or review the interpretation of the EKG. Documentation of the physician's request must be kept in the Patient's medical record. A Community Health Center may claim payment for EKG services only when the Community Health Center owns or rents its own EKG equipment and the EKG is taken at the Community Health Center.7.Family Planning Services. The Health Safety Net pays for family planning counseling, prescribed drugs, family planning supplies, and laboratory tests.8.Individual Medical Visits. The Health Safety Net pays for face-to-face meetings at a Community Health Center between a Patient and a physician, physician assistant, nurse practitioner, nurse midwife, registered nurse, or paraprofessional for medical examination, diagnosis, or treatment.9.Laboratory Services. The Health Safety Net pays only for laboratory services for which a written request for that service from an authorized subscriber is present in the Patient's medical record. The Office does not pay for the following laboratory services: routine specimen collection and preparation for the purpose of clinical laboratory analysis (for example, venipunctures, urine, fecal, and sputum samples; Pap smears; cultures; and swabbing and scraping for removal of tissue); laboratory tests associated with treatment of male or female infertility (however, the Health Safety Net pays for the diagnosis of male and female infertility); or such calculations as red cell indices, A/G ratio, creatinine clearance, and those ratios calculated as part of a profile. The Office does not pay a Community Health Center for a laboratory service when the Community Health Center bills separately for the professional component of that service.10.Medical Nutrition Therapy. The Health Safety Net pays for medical nutrition therapy services as defined by Subchapter 6 of the MassHealth Community Health Center Manual. Medical nutrition therapy does not include enteral therapy.14.Radiology Services. The Health Safety Net pays for radiology services only when the services are provided at the written request of a licensed physician or dentist. The professional component of a radiology service is the component for interpreting a diagnostic test or image. The technical component of a radiology service is the component for the cost of rent, equipment, utilities, supplies, administrative and technical supplies and benefits, and other overhead expenses.16.Tobacco Cessation Services. The Health Safety Net pays for tobacco cessation services as defined by Subchapter 6 of the MassHealth Community Health Center Manual.18.Immunization Visits and Vaccines.(c)Reimbursable Health Services Requirements. The Health Safety Net pays only for services provided by the licensed professionals listed in the HSN CHC Billable Procedure Codes list and pays in accordance with 101 CMR 614.00: Health Safety Net Payments and Funding.Amended by Mass Register Issue 1271, eff. 10/10/2014.Amended by Mass Register Issue 1304, eff. 1/15/2016.Amended by Mass Register Issue 1310, eff. 4/8/2016.Amended by Mass Register Issue 1329, eff. 10/1/2016.Amended by Mass Register Issue 1359, eff. 2/23/2018.Amended by Mass Register Issue 1474, eff. 7/8/2022 (EMERGENCY).Amended by Mass Register Issue 1481, eff. 7/8/2022 (COMPLIANCE).