CurrentOptumPolicy N/A

Guidelines for Medical Necessity Determination for Community Support Program

Defines clinical criteria, coverage rules, and documentation requirements MassHealth uses to determine medical necessity for Community Support Program and specialized CSP services for members with behavioral health disorders in Massachusetts.

Policy Summary

PayerOptum

PolicyGuidelines for Medical Necessity Determination for Community Support Program

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 12, 2024

Next Review DateN/A

Key ActionNo prior authorization is required for CSP services; verify member eligibility and document clinical criteria per 130 CMR 461.414.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No PAPA requirement for CSP

180dDischarge lookback (general CSP)

4/12moFrequent ED use (CSP-HI)

120dPSH timeframe (CSP-HI)

Coverage and Medical Necessity Criteria

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General CSP medical necessity: 1) The member has a behavioral health disorder diagnosis; 2) The member demonstrates a need for behavioral health diversionary services and is at risk of admission to 24-hour behavioral health inpatient services as demonstrated by at least one specified recent encounter (a recent discharge from a 24-hour behavioral health inpatient or diversionary level of care within the past 180 days; OR more than one acute behavioral health services encounter within the past 90 days, including AMCI/YMCI, Adult or Youth CCS/YCCS, ED services, urgent behavioral health services, or restoration center encounters; OR documented barriers to accessing or consistently utilizing medical and behavioral health services); 3) The member does not require a more intensive level of service (including structure or supervision beyond the scope of CSP) and does not have medical conditions or impairments that would prevent utilization of services or pose an imminent risk to self or others; 4) The member voluntarily consents to CSP and has the ability to participate in all aspects of services.see child nodes

See Section B for details

inv-02: Specialized CSP Eligibility (CSP-HI, CSP-JI, CSP-TPP)

Specialized CSP covered when ALL of the following (service-specific) are met

CSP-HI criteria: a) Clinical: member meets the clinical criteria for CSP (Section B) as verified by diagnosis or member attestation (for certain plans on/after Jan 1, 2025, HNBC may qualify as alternative verification); b) Housing status: member is experiencing chronic homelessness OR experiencing homelessness and is a frequent user of acute MassHealth services (either four or more ED visits within the past 12 months OR three or more acute and/or psychiatric hospital inpatient admissions within the past 12 months); c) Imminent housing: member has identified a PSH opportunity and will move into housing within 120 days of initiation of services, OR is receiving homeless medical respite services per 130 CMR 458.000, OR is being discharged from homeless medical respite services with an identified PSH opportunity and will move into housing within 120 days of discharge.see thresholds

CSP-HI specific criteria

CSP-JI criteria: a) Clinical: member meets the clinical criteria for CSP (Section B); b) Justice involvement: member has justice involvement when services begin; c) Barrier to care: member has documented barriers to accessing or consistently utilizing essential medical and behavioral health services as evidenced by at least one of the following—antisocial behaviors (including criminal activity or Antisocial Personality Disorder), cyclical relapse with justice involvement, repetitive high-risk behaviors, insufficient community/social supports, or being identified as high risk of recidivism on validated assessments—and demonstrates need for diversionary services and risk of 24-hour inpatient admission with modified timeframes (discharge or multiple acute encounters within the past year or documented barriers).modified timeframes (1 year)

CSP-JI specific criteria

CSP-TPP criteria: a) Clinical: member meets the clinical criteria for CSP (Section B); b) Housing risk: member is at risk of homelessness; c) Eviction/tenancy preservation: member is facing eviction when services begin, except members whose eviction cases already went to trial in District Court or Boston Municipal Court are not eligible (Housing Court trial outcomes may affect eligibility). For certain plans on/after Jan 1, 2025, HNBC may qualify as alternative verification.eviction status exceptions

CSP-TPP specific criteria

Coding-related Criteria and Lookbacks

inv-05: Frequent ED use for CSP-HI — four or more ED visits within the past 12 months

ThresholdFour or more emergency department (ED) visits within the past 12 months from the date of evaluation for CSP-HI.

Applies toCSP-HI (Homelessness-focused specialized CSP).

Use in eligibility determinationCounts toward demonstrating 'frequent acute MassHealth services' when assessing housing-status criterion for CSP-HI.

inv-06: Frequent inpatient use for CSP-HI — three or more acute and/or psychiatric inpatient admissions within the past 12 months

ThresholdThree or more acute and/or psychiatric hospital inpatient admissions within the past 12 months from the date of evaluation for CSP-HI.

Applies toCSP-HI (Homelessness-focused specialized CSP).

Use in eligibility determinationCounts toward demonstrating 'frequent acute MassHealth services' when assessing housing-status criterion for CSP-HI.

inv-07: Acute behavioral health encounters lookback — general CSP 90 days; CSP-JI within past year; discharge from 24-hour inpatient lookback 180 days

General CSP lookbackAcute behavioral health encounters considered if occurring within the past 90 days (e.g., ED visits, AMCI/YMCI, Adult CCS/YCCS, urgent/restoration services).

CSP-JI lookbackFor CSP-JI, modified timeframe: acute behavioral health encounters or discharges considered if within the past year (12 months).

Recent inpatient discharge lookback for general CSPBeing discharged from a 24-hour behavioral health inpatient or diversionary level of care within the past 180 days qualifies as evidence of need.

Service Setting / Level of Care Requirements

inv-16: Outpatient / Community-based

Outpatient / Community-based level-of-care requirements: Services are outpatient, community-based, and mobile supports; medical necessity requires that the member does not require a more intensive level of service (e.g., structured or supervised care beyond CSP scope) and can participate in services; level-of-care determination uses the CSP admission, continued stay, and discharge considerations in Section B and modified timeframes for specialized CSP when applicable.

See Section B and Specialized CSP sections for timeframes and lookback windows

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior authorization not required

No prior authorization is required for Community Support Program (CSP) services. Payment is subject to member eligibility, other insurance, and program restrictions.

Applies to all CSP and specialized CSP services

Note

Provider action — consult applicable policies

Providers must consult applicable MassHealth regulations and the member’s managed care plan policies where relevant. Providers serving members in MassHealth-contracted plans should refer to those plans' medical policies for covered services.

See 130 CMR 450.000 and 130 CMR 461.000; MCE Bulletin 99

Documentation Required

Recordkeeping and documentation

Maintain member records in accordance with 130 CMR 450.000 and 130 CMR 461.414. Records must include written documentation that the member receiving services meets the clinical standards published by MassHealth.

Documentation must demonstrate that the member meets the Guidelines' clinical standards
Follow MassHealth recordkeeping and billing regulations

Denial Risk

Noncoverage for noncompliant services

MassHealth does not pay for CSP or specialized CSP services provided to members who do not meet these Guidelines. Additional service limitations are set forth in 130 CMR 461.417.

Services provided to non‑eligible members are not covered
See 130 CMR 461.417 for service limitations

Key Definitions

inv-13: At Risk of Homelessness — definition and explanatory note

DefinitionAt Risk of Homelessness: any member who does not have sufficient resources or support networks immediately available to prevent moving to an emergency shelter or place not meant for human habitation.

Examples of insufficient supportsLack of family, friends, faith-based, or other social networks to prevent imminent loss of housing.

Use in specialized CSP (TPP)Used to establish housing-risk criterion for CSP-TPP eligibility when a member is facing eviction or imminent loss of housing.

inv-14: Health Needs Based Criteria (HNBC) — qualifying conditions and summary

DefinitionHealth Needs Based Criteria (HNBC): an individual who has one or more qualifying conditions such as a behavioral health need, a complex physical health need, need for assistance with ADLs/IADLs, repeated ED use, or specified pregnancy/postpartum conditions.

Qualifying conditions (examples)Behavioral health need requiring stabilization; complex physical health need; need for ADL/IADL assistance; repeated ED use (≥2 in 6 months or ≥4 in 12 months); high-risk pregnancy or specified postpartum periods.

Role in eligibilityFor some plans beginning Jan 1, 2025, HNBC may qualify as alternative verification for specialized CSP eligibility (per coverage criteria notes).

inv-15: Homelessness / Chronic Homelessness — definition details

Homelessness definitionLacking a fixed, regular, and adequate nighttime residence, including sleeping in places not meant for habitation (e.g., car, park, abandoned building) or living in supervised emergency shelters, transitional housing, or hotels/motels paid for by programs for low-income individuals.

Chronic HomelessnessDefined by the U.S. Department of Housing and Urban Development (HUD) as referenced in the policy; used for CSP-HI housing-status criterion.

Contextual useDistinguishes members experiencing homelessness (including chronic homelessness) for specialized CSP eligibility such as CSP-HI.

Program Background

The Community Support Program (CSP) provides community-based, mobile, paraprofessional supports for members with behavioral health disorders whose symptoms or service access barriers threaten community tenure or create risk for 24-hour behavioral health inpatient admission. CSP services are designed as diversionary and rehabilitative interventions to address functional needs, assist with linkage to medical and social services, and reduce repeated acute service use. Coverage requires documentation that the member meets the program’s clinical standards, is able and willing to participate, and demonstrates need for diversionary services or recent acute encounters as specified in the Guidelines.

Service Limits and Visit-related Rules

inv-17: CSP and specialized CSP — subject to service limitations in 130 CMR 461.417

Service limitations referenceCSP and specialized CSP services are subject to service limitations set forth in 130 CMR 461.417.

Regulatory guidanceProviders must follow MassHealth regulations at 130 CMR 450.000 (All Providers) and 130 CMR 461.000 (Community Support Program Services) for coverage and requirements.

Payment and coverage noteMassHealth does not pay for CSP services provided to members who do not meet these Guidelines; additional limitations are in 130 CMR 461.417.