130 CMR, § 405.474

Current through Register 1538, January 3, 2025

Section 405.474 - Acupuncture Services

(A)Introduction. MassHealth members are eligible to receive acupuncture services in CHCs for the treatment of pain as described in 130 CMR 405.474(C). See130 CMR 433.454(C): Medical Direction of Anesthesia Services for use of acupuncture as an anesthetic, and 130 CMR 418.000: Substance Use Disorder Treatment Services for use of acupuncture for detoxification.

(B)General. 130 CMR 405.474 applies specifically to physicians and other licensed practitioners of acupuncture in a CHC. The requirements elsewhere in 130 CMR 405.000 that apply to a CHC, also apply to licensed practitioners of acupuncture, such as service limitations, recordkeeping, report requirements, and prior-authorization requirements.

(C)Acupuncture for the Treatment of Pain. MassHealth provides a total of 20 sessions of acupuncture for the treatment of pain per member per year without prior authorization. If the member's condition, treatment, or diagnosis changes, the member may be able to receive more sessions of medically-necessary acupuncture treatment with prior authorization.

(D)Provider Qualifications for Acupuncture.

(1)Qualified Providers. MassHealth pays a CHC for acupuncture services only when the provider rendering the service is:

(a) a physician; or

(b) licensed in acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture.

(2)Acupuncture Providers in CHCs. CHCs must ensure that acupuncture providers for whom the CHC will submit claims possess the appropriate training, credentials, and licensure.

(E)Conditions of Payment. The MassHealth agency pays the CHC for services of an acupuncturist qualified to render such services in accordance with 130 CMR 405.474(D) only when the:

(1) the services are limited to the scope of practice authorized by state law or regulation (such as 243 CMR 5.00: The Practice of Acupuncture); and

(2) the provider has a current license or certificate of registration from the Massachusetts Board of Registration in Medicine.

(F)Acupuncture Claims Submissions.

(1) Community health centers (CHCs) may submit claims for acupuncture services when a provider qualified to render such services in accordance with 130 CMR 405.474(D) provides those services directly to MassHealth members. See Subchapter 6 of the Community Health Center Manual for service code descriptions and billing requirements.

(2) For MassHealth members receiving services under any of the acupuncture codes on the same date of service as an office visit, the CHC may bill for either an office visit or the acupuncture code, but may not bill for both an office visit and the acupuncture code for the same member on the same date when the office visit and the acupuncture services are performed in the same location. This limitation does not apply to a significant, separately identifiable office visit provided by the same CHC on the same day of the acupuncture service.