130 CMR 412.00 — Renal Dialysis Clinic Services

Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series

SUBCHAPTER NUMBER AND TITLE

TABLE OF CONTENTS

PAGE

iv

RENAL DIALYSIS CLINIC MANUAL

TRANSMITTAL LETTER

REN-9

DATE

12/15/01

4. PROGRAM REGULATIONS

412.401 Introduction ..................................................................................................................... 4-1 (130 CMR 412.402 and 412.403 Reserved) 412.404 Eligible Members ............................................................................................................ 4-1 412.405 Provider Eligibility .......................................................................................................... 4-1 (130 CMR 412.406 and 412.407 Reserved) 412.408 Maximum Allowable Fees ............................................................................................... 4-2 412.409 Covered Services ............................................................................................................. 4-2

Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series

SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 412.000)

PAGE

4-1

RENAL DIALYSIS CLINIC MANUAL

TRANSMITTAL LETTER

REN-9

DATE

12/15/01

130 CMR 412.00 Renal Dialysis Clinic Services

412.401 Introduction

412.401: Introduction

130 CMR 412.000 establishes the Division’s requirements for providers of renal dialysis clinic services. All providers of renal dialysis clinic services participating in MassHealth must comply with the regulations of the Division governing MassHealth including but not limited to the Division's regulations at 130 CMR 412.000 and 450.000.

(412.402 and 412.403 Reserved)

412.404 Eligible Members

412.404: Eligible Members

(A) (1) MassHealth Members . The Division covers renal dialysis clinic services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in 130 CMR 412.000, 450.000, and 501.000 through 512.000. 130 CMR 450.105 specifically states, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program . For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.

(B) Member Eligibility and Coverage Type . For information on verifying member eligibility and coverage type, see 130 CMR 450.107.

412.405 Provider Eligibility

412.405: Provider Eligibility

A renal dialysis clinic must be a participant in MassHealth on the date of service in order to be eligible for payment.

(A) In-State Providers . To be eligible for participation as a MassHealth provider, a renal dialysis clinic must be: (1) located and doing business in the Commonwealth of Massachusetts; (2) enrolled as a Medicare provider; and (3) licensed as an out-of-hospital dialysis unit by the Massachusetts Department of Public Health, Bureau of Hospital Facilities.

(B) Out-of-State Providers . A provider that does not meet the requirements of 130 CMR 412.405(A)(1) and (3) may participate in and receive payment from MassHealth only if the provider is licensed in its own state as an out-of-hospital dialysis unit and meets the requirements of 130 CMR 412.405(A)(2) and 450.109.

(C) Multiple Facilities . When two or more renal dialysis clinics have the same director or owner, whether or not the clinics have different names, each clinic must enroll separately with MassHealth and have its own MassHealth provider number.

(412.406 and 412.407 Reserved)

Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series

SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 412.000)

PAGE

4-2

RENAL DIALYSIS CLINIC MANUAL

TRANSMITTAL LETTER

REN-9

DATE

12/15/01

412.408 Maximum Allowable Fees

412.408: Maximum Allowable Fees

The Massachusetts Division of Health Care Finance and Policy determines the maximum allowable fees for renal dialysis clinic services. Payment is always subject to the conditions, exclusions, and limitations set forth in 130 CMR 450.000. The maximum allowable fees for renal dialysis clinic services are the lowest of the following:

(A) the clinic's usual and customary fee;

(B) the clinic's actual charge submitted; or

(C) the maximum allowable fee listed in the applicable Division of Health Care Finance and Policy fee schedule.

412.409 Covered Services

412.409: Covered Services

(A) Renal Dialysis . The Division covers medically necessary renal dialysis for eligible MassHealth members. Renal dialysis includes all services, supplies, and routine laboratory tests as specified in Subchapter 6 of the Renal Dialysis Clinic Manual.

(B) Prescribed Drugs . The Division limits payment to dialysis clinics for prescribed drugs to those specified in the service codes and descriptions in Subchapter 6 of the Renal Dialysis Clinic Manual.

(C) Training for Home Dialysis . The Division pays for home dialysis training, including self-dialysis (hemodialysis, intermittent peritoneal dialysis, and continuous cycling peritoneal dialysis) and continuous ambulatory peritoneal dialysis training only where the MassHealth member attends such training at the clinic site.

REGULATORY AUTHORITY

130 CMR 412.000: M.G.L. c. 118E, §§7 and 12.