130 CMR 447.00 — Acupuncture Services

4. Program Regulations:

130 CMR 447.000: Acupuncture Services

130 CMR 447.00 Acupuncture Services

447.401 Introduction .............................................................................................. 4-1

447.401: Introduction .............................................................................................. 4-1

447.402 Definitions ................................................................................................. 4-1

447.402: Definitions ................................................................................................. 4-1

447.403 Eligible Members ....................................................................................... 4-1

447.403: Eligible Members ....................................................................................... 4-1

447.404 Provider Eligibility ..................................................................................... 4-2

447.404: Provider Eligibility ..................................................................................... 4-2

447.405 Maximum Allowable Fees .......................................................................... 4-3

447.405: Maximum Allowable Fees .......................................................................... 4-3

447.406 Reporting Requirements ............................................................................. 4-3

447.406: Reporting Requirements ............................................................................. 4-3

447.407 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services .......... 4.3

447.407: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services .......... 4.3 (130 CMR 447.408 through 447.412 Reserved) ................................................................

447.413 Covered Services ....................................................................................... 4-3

447.413: Covered Services ....................................................................................... 4-3

447.414 Noncovered Services ................................................................................. 4-3

447.414: Noncovered Services ................................................................................. 4-3

447.415 Service Limitations .................................................................................... 4-3

447.415: Service Limitations .................................................................................... 4-3

447.416 Prior Authorization .................................................................................... 4-4

447.416: Prior Authorization .................................................................................... 4-4

447.417 Recordkeeping Requirements ...................................................................... 4-4

447.417: Recordkeeping Requirements ...................................................................... 4-4

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Acupuncture Services Manual Transmittal Letter ACU-1 Date 01/21/22

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title

1. Introduction (130 CMR 447.000) Page 4-1 Acupuncture Services Manual Transmittal Letter ACU-1 Date 01/21/22

447.401 Introduction

447.401: Introduction

130 CMR 447.000 establishes the requirements for the provision and payment of acupuncture services under MassHealth. All acupuncturists participating in MassHealth must comply with MassHealth regulations including, but not limited to, 130 CMR 447.000 and 130 CMR 450.000: Administrative and Billing Regulations.

447.402 Definitions

447.402: Definitions

The following terms used in 130 CMR 447.000 have the meanings given in 130 CMR 447.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 447.000 is not determined by these definitions, but by application of 130 CMR 447.000 and 130 CMR 450.000: Administrative and Billing Regulations.

Acupuncture – the insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, with or without the application of an electric current, and with or without the application of heat to the needles, skin, or both.

Dry Needling – the use of solid needles to treat muscle pain by stimulating and breaking muscular knots and bands.

Office Visit – a visit by a MassHealth member to an acupuncturist’s office for evaluation and management services performed by a MassHealth-enrolled acupuncturist.

447.403 Eligible Members

447.403: Eligible Members

(A) (1) MassHealth Members. The MassHealth agency pays for acupuncture services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105: Coverage Types specifically states, for each 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: Emergency Aid to the Elderly, Disabled and Children Program.

(B) For information on verifying member eligibility and coverage types, see 130 CMR 450.107: Eligible Members and the MassHealth Card.

447.404 Provider Eligibility

447.404: Provider Eligibility

The MassHealth agency pays only acupuncturists who are participating in MassHealth on the date of service. Acupuncturists must meet the following eligibility requirements.

(A) In-state Providers. To be eligible to participate in MassHealth, an in-state acupuncturist must (1) be licensed as a provider of acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture; and (2) be an active MassHealth provider.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title

1. Introduction (130 CMR 447.000) Page 4-2 Acupuncture Services Manual Transmittal Letter ACU-1 Date 01/21/22

(B) Out-of-state Providers. To participate in MassHealth, an out-of-state acupuncturist must obtain a MassHealth provider number and meet the following criteria: (1) be currently licensed as an acupuncturist in his or her own state, or for an acupuncturist in a state that does not license acupuncturists, be legally authorized to perform the services of an acupuncturist in that state; (2) participate in his or her state’s Medicaid program (or the equivalent); and (3) meet the conditions set forth in 130 CMR 450.109: Out-of-state Services.

447.405 Maximum Allowable Fees

447.405: Maximum Allowable Fees

The Executive Office of Health and Human Services (EOHHS) determines the payment rate for acupuncture services in accordance with 101 CMR 317.00: Rates for Medicine Services. Payment is subject to the conditions, exclusions, and limitations set forth in 130 CMR 447.000 and 130 CMR 450.000: Administrative and Billing Regulations.

447.406 Reporting Requirements

447.406: Reporting Requirements

Acupuncturists who furnish services to MassHealth members must report the results of these services to the member’s primary care provider or Primary Care Clinician (PCC) in writing. The acupuncturist may report the results of treatment initially by telephone, but he or she must then submit a written report of the initial consultation and subsequent periodic re-evaluations.

447.407 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

447.407: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

The MassHealth agency pays for all medically necessary acupuncture services for EPSDT- eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services: Introduction, without regard to service limitations described in 130 CMR 447.000, and with prior authorization.

(130 CMR 447.408 through 447.412 Reserved)

447.413 Covered Services

447.413: Covered Services

(A) The MassHealth agency pays for medically necessary acupuncture for the treatment of pain and for use for detoxification as described in 130 CMR 418.406(D)(4): Acupuncture Detoxification. Services must address the patient’s condition and if no clinical benefit is appreciated after four sessions, then the treatment plan must be re-evaluated. Further acupuncture treatment is not considered medically necessary if the patient does not demonstrate meaningful improvement in symptoms. (B) The MassHealth agency will pay for one office visit per member every four weeks. A provider may bill the MassHealth agency for both an office visit and acupuncture treatment rendered to a member on the same day in accordance with these regulations.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title

1. Introduction (130 CMR 447.000) Page 4-3 Acupuncture Services Manual Transmittal Letter ACU-1 Date 01/21/22

447.414 Noncovered Services

447.414: Noncovered Services

The MassHealth agency does not pay for the following:

(A) dry needling;

(B) acupuncture for purposes other than those identified in 130 CMR 447.413(A);

(C) performing, administering, or dispensing any experimental, unproven, cosmetic, or otherwise medically unnecessary procedure or treatment;

(D) the treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment); or

(E) otherwise payable service codes when those codes are used to bill for circumstances that are not payable under 130 CMR 447.414.

447.415 Service Limitations

447.415: Service Limitations

The MassHealth agency limits payment for acupuncture services to a total of 20 treatments per member per calendar year, without prior authorization. Acupuncture treatments above these limits require prior authorization in accordance with 130 CMR 447.416.

447.416 Prior Authorization

447.416: Prior Authorization

(A) Services that Require Prior Authorization. The MassHealth agency requires that the acupuncturist obtain prior authorization as a prerequisite to payment for more than 20 treatments per member per calendar year.

(B) Submission Requirement. The acupuncturist must submit all prior authorization requests in accordance with the billing instructions in Subchapter 5 of the Acupuncture Manual. Prior authorization determines only the medical necessity of the authorized service, and does not establish or waive any other prerequisites for payment, such as member eligibility, or resort to health insurance payment. See 130 CMR 450.303: Prior Authorization for additional information about prior authorization.

(C) Notice of Approval or Denial of Prior Authorization. (1) Notice of Approval. For all approved prior authorization requests for acupuncture services, the MassHealth agency sends written notice to the member and the acupuncturist about the frequency, duration, and intensity of care authorized, and the effective date of authorization. (2) Notice of Denial or Modification and Right of Appeal. (a) For all denied or modified prior authorization requests, the MassHealth agency notifies both the member and the acupuncturist of the denial or modification and the reason. In addition, the member will receive information about the member’s right to appeal and the appeal procedure.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title

1. Introduction (130 CMR 447.000) Page 4-4 Acupuncture Services Manual Transmittal Letter ACU-1 Date 01/21/22

(b) A member may request a fair hearing from the MassHealth agency if it denies or modifies a prior authorization request. The member must request a fair hearing in writing within 30 days after the date of receipt of the notice of denial or modification. The MassHealth Board of Hearings will conduct the hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules.

447.417 Recordkeeping Requirements

447.417: Recordkeeping Requirements

(A) Federal and state regulations require that all MassHealth providers maintain complete written medical records of all patients who are MassHealth members. Medical records must comply with the provisions of 233 CMR 4.04: Insurance Requirements for Limited Liability Companies and Limited Liability Partnerships. All records must be kept for a minimum of six years after the date of service. Payment for maintaining the member's medical record is included in the fee for acupuncture services. Each medical record must contain sufficient information to document fully the nature, extent, quality, and necessity of the care furnished to the member for each date of service claimed for payment. If the documentation is not sufficient to justify the service for which payment is claimed by the provider, the MassHealth agency will not pay for the service or, if payment has been made, may consider such payment to be an overpayment subject to recovery in accordance with 130 CMR 450.000: Administrative and Billing Regulations.

(B) The medical records must contain the following: (1) MassHealth member identification, including name, address, telephone number, date of birth, and the MassHealth member’s identification number; (2) a complete medical history; (3) examination results, including a description of the chief complaint and diagnosis; (4) a written referral from the member's primary care provider or PCC; (5) copies of all prior authorization requests for out-of-state services; (6) the date and nature of each visit, including a complete description of services furnished, written and signed by the acupuncturist; (7) when more than one visit is indicated, a treatment plan for future visits written and signed by the acupuncturist, which is updated on an ongoing basis to reflect changes in the member’s presenting symptoms; (8) upon completion of treatment, a summary of the treatment and the member's current condition; (9) recommendations for additional treatment, signed and dated by the acupuncturist; and (10) if the medical record or any component included therein is released for use by another party, the medical record must also contain a release form signed by the member. Release of the medical record to MassHealth for authorized use does not require the member's consent.

REGULATORY AUTHORITY

130 CMR 447.000: M.G.L. c 118E, §§ 7 and 12.