The Commonwealth of Massachusetts
Executive Office of Health and Human Services
www.mass.gov/masshealth

Home Health Coverage Determination Form
(Attach EOB from primary insurer to this form.)

Send to: MassHealth
Home Health Claims
The Schraffts Center
529 Main Street, 3rd Floor
Charlestown, MA  02129
Fax: 617-886-8133

Provider Name: 
Provider Address: 
Branch Address:
Contact Name:
Contact Phone/Fax No.:
MassHealth Provider No.:
NPI:

Date:
Member Name: Member ID:
Diagnosis:
Dates of Service:    to 

Services Provided (Check all that apply.):
Skilled Nursing  Continuous Skilled Nursing  Physical Therapy
Occupational Therapy  Speech/Language Pathology  Home Health Aide

Qualifying/Triggering Event (Check one.):
New admission to a home health agency (HHA)
A readmission to an HHA after a discharge from an inpatient hospital or skilled 
facility stay; resulting in a change of skilled services in the plan of care 
Cessation of commercial insurance coverage or a change of insurance(attach a 
completed TPLI form)
Exhaustion of annual commercial insurance coverage or other periodic benefit(s)  
Reinstatement of insurance benefits  Change in the patient’s medical condition 
resulting in a change of skilled services in the plan of care

Please provide a brief description of change:

Is this a personal injury protection (PIP) case?   yes       no

Are you covending?    yes       no
If yes, name of covendor:  

HHCD-1 (01/09)

Purpose of Home Health Coverage Determination (HHCD) Form

The MassHealth HHCD Form is used by home health agencies to show compliance with 
MassHealth’s third-party liability (TPL) regulations (130 CMR 450.316 and 
450.317). For members with commercial insurance in addition to MassHealth, 
providers must submit claims to the commercial insurer for a coverage 
determination before submitting the claim to MassHealth. Coverage determinations 
and explanations of benefits (EOBs) must be obtained whenever a member has a 
qualifying event. The HHCD Form must accompany the coverage determination and/or 
EOB to MassHealth within 10 days of the provider’s receipt of the EOB. Home 
health providers must continue to submit paper coverage determinations for all 
qualifying events whether billing electronically or on paper.

Instructions for Completing the HHCD Form

Provider Information:
Fill in your provider name, branch address, and contact’s phone and fax numbers.

MassHealth Provider No.: 
Fill in your MassHealth provider number.

NPI:
Fill in your national provider identifier (NPI) number.

Date:
Fill in the date you are sending the form and accompanying EOB to MassHealth.

Member Name:
Fill in the member’s name.

Member ID:
Fill in the member’s ID number.

Diagnosis:
Fill in the diagnosis/diagnoses; ICD-9 codes are not necessary.

Dates of Service:
Fill in the dates you want MassHealth to start and end payment. If there is no 
end date, enter a start date and indicate “ongoing.”

Services Provided:
Check off all services the agency is providing to the member.

Qualifying/Triggering Event:
Check off the reason the provider obtained the initial EOB or new EOB. If you 
are notifying us of a change in insurance, please complete both the HHCD Form 
and the TPLI form and send both with the EOB. Both forms are accessible from the 
MassHealth Web site at www.mass.gov/masshealth by clicking on the link for 
MassHealth Provider Forms in the lower right corner of the page.

Description of Change:
Indicate why the primary insurance company was billed.