MassHealth Provider Manual Appendices

Appendices for All Provider Manuals

MassHealth updates the generic appendices contained in all provider manuals (Appendices A, B, C, W, X, Y, and Z) as needed.  Paper copies of these appendices are not mailed automatically to providers, but can be requested by calling, faxing, e-mailing, or mailing a request to:

Phone: 1-800-841-2900
Fax:     617-988-8973
E-mail: publications@mahealth.net
Mailing address:
           MassHealth Publications
           P.O. Box 9118
           Hingham, MA 02043

• Appendix A: Directory (PDF) | TEXT
  This appendix contains the names, addresses, and telephone numbers of units, agencies, and contractors that you may need to contact in the course of doing business with MassHealth.

• Appendix B: Enrollment Centers (PDF) | RTF 1.18MB
  This appendix lists for each of the four regional MassHealth Enrollment Centers the address, telephone and fax numbers, responsibilities, and towns they serve.

• Appendix C: Third-Party-Liability Codes (PDF) | TEXT
  This appendix contains lists of third-party-liability (TPL) coverage-type codes and carrier codes to help you identify a member's other insurance. The MassHealth Recipient Eligibility Verification System (REVS) reports TPL coverage-type and carrier codes for all applicable insurance coverage listed on file for each member.

• Appendix W: EPSDT Services Medical and Dental Protocol and Periodicity Schedule (PDF) | RTF
  This appendix lists the services required under the Early and Periodic Screening, Diagnosis and Treatment (EPDST) Program, and the ages at which those services must be provided.

• Appendix X: Family Assistance Co-payments and Deductibles (PDF) | RTF
  MassHealth will pay for certain copayments, deductibles, and coinsurance amounts for certain MassHealth Family Assistance members under age 19. This appendix describes who is eligible, the types of copayments, deductibles, and coinsurance amounts that are covered, and how to bill for these services.

• Appendix Y: EVS Codes and Messages (PDF) | TEXT
  This appendix lists the active Eligibility Verification System (REVS) codes and their respective service restriction messages.

• Appendix Z: EPSDT/PPHSD Screening Services Codes (PDF) | RTF
  This appendix lists the services that are payable in addition to the EPSDT periodic visit when they are performed and interpreted in the office of the provider who furnished the visit.

Provider-Specific Appendices

Updates to provider-specific manual appendices are automatically mailed to relevant providers.

Acute Inpatient Hospitals

• Appendix D: Supplemental Instructions for Claims with Other Insurance (PDF) | TEXT
  This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

• Appendix E: Information Required for the Utilization Management Program (PDF) | TEXT
  This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission.  It also provides contact information for the MassHealth Utilization Management Program contractor.

• Appendix F: Admission Guidelines (PDF) | TEXT
  This appendix contains a crosswalk of revenue codes and related HCPCS codes.

Acute Outpatient Hospitals

• Appendix D: Utilization Management Program (PDF) | TEXT
  This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission.  It also provides contact information for the MassHealth Utilization Management Program contractor.

• Appendix E: Admission Guidelines (PDF) | TEXT
  This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

• Appendix F: Revenue Codes (PDF) | TEXT
  This appendix contains a crosswalk of revenue codes and related HCPCS codes.

Adult Day Health Manual

• Appendix D: Dementia Day Service (PDF) | TEXT
  This appendix contains guidelines for adult day health programs that offer services to dementia populations.

Chronic Disease and Rehabilitation Inpatient Hospital Manual

• Appendix D: Supplemental Instructions for Claims with Other Insurance (PDF) | TEXT
  This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

Community Health Center Manual

• Appendix E: Utilization Management Program (PDF) | TEXT
  This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission.  It also provides contact information for the MassHealth Utilization Management Program contractor.

• Appendix F: Admission Guidelines (PDF) | TEXT
  This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Dental Manual

• Appendix G: Utilization Management Program (PDF) | TEXT
  This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission.  It also provides contact information for the MassHealth Utilization Management Program contractor.

• Appendix H: Admission Guidelines (PDF) | TEXT
  This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Durable Medical Equipment Manual

• Appendix D: ASAP Directory for PERS (PDF) | TEXT
  This appendix is a list of addresses for local aging service access points (ASAPs), where requests for prior authorization for personal emergency response systems (PERS) should be sent.

Freestanding Ambulatory Surgery Center Manual

• Appendix E: Admission Guidelines (PDF) | TEXT
  This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Home Health Agency Manual

• Appendix D: Supplemental Instructions for TPL Exceptions (PDF) | TEXT
  This appendix contains billing instructions for submitting 837I and 837P transactions, paper claims, and direct data entry (DDE) claims for members who have Medicare or commercial insurance, and whose services are determined not covered by the primary insurer. This appendix lists the exceptions that need to be considered when billing MassHealth, for members who have Medicare or commercial insurance. These are specific MassHealth billing instructions that are not described in the HIPAA implementation guides for the 837I and 837P transactions, in the 837I and 837P companion guides, or in the billing guides for the UB-04 or CMS-1500 claim forms.

Nursing Facility Manual

• Appendix D: Specification for Electronic Submission of MMQ (PDF) | TEXT
  This appendix provides specifications for submitting Management Minutes Questionnaire (MMQ) information electronically.

• Appendix E: Instructions for Completing MMQ (PDF) | TEXT
  This appendix provides instructions for completing initial and semiannual Management Minutes Questionnaires (MMQ).

• Appendix F: Unit-Dose Drugs (PDF) | TEXT
  This appendix lists the unit-dose packaged drugs that a nursing facility must return to the dispensing pharmacy in accordance with 130 CMR 456.621, when the use of the drug for the member is discontinued.
  
• Appendix G: Supplemental Instructions for TPL Exceptions (PDF) | TEXT
  This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

Pharmacy Manual

• Appendix D: Unit-Dose Drugs (PDF) | RTF
  This appendix lists the unit-dose-packaged drugs that the dispensing pharmacy must credit to MassHealth when they have been dispensed to a MassHealth member in a nursing facility and have been returned by the nursing facility in accordance with 130 CMR 406.446.

Physician Manual

• Appendix E: Admission Guidelines (PDF) | RTF
  This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

• Appendix I: Utilization Management Program (PDF) | TEXT
  This appendix is a list of information the admitting provider or designee must give the MassHealth Utilization Management contractor when proposing an elective admission. MassHealth may request additional information at any time to clarify the details of any admission. See 130 CMR 450.208 for regulations about admission screening.

• Appendix K: Teaching Physicians (PDF) | TEXT
  This appendix contains service codes for which a teaching physician may bill MassHealth even though he or she is not physically present for the key portions of the service.   Note:  This exception does not apply in certain circumstances if the teaching physician is also a primary care clinician in the Primary Care Clinician Plan.  (See 130 CMR 450.275.)

Podiatrist Manual

• Appendix E: Utilization Management Program (PDF) | TEXT
  This appendix is a list of information the admitting provider or designee must give the MassHealth Utilization Management contractor when proposing an elective admission. MassHealth may request additional information at any time to clarify the details of any admission. See 130 CMR 450.208 for regulations about admission screening.

• Appendix F: Admission Guidelines (PDF) | TEXT
  This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Psychiatric Inpatient Hospital

• Appendix D: Supplemental Instructions for TPL Exceptions (PDF) | TEXT
  This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

Sterilization Clinic Manual

• Appendix E: Utilization Management Program (PDF) | TEXT
  This appendix is a list of information the admitting provider or designee must give the MassHealth Utilization Management contractor when proposing an elective admission. MassHealth may request additional information at any time to clarify the details of any admission. See 130 CMR 450.208 for regulations about admission screening.