Status Change for Members in a Nursing Facility or Chronic Disease and 
Rehabilitation Inpatient Hospital 
(Admission or Discharge of MassHealth Members) 
SECTION 1 ( Items 1 through 12 must be completed.)  
1. Provider ID/Service Location  2. Provider Name  3. Provider Telephone Number  
4. Provider Address  5. Reason for Submission New SC-1 Change to Existing SC-1  
6. Member Last Name  7. Member First Name  8. Middle Initial  
9. Member Home Address  
10. Member Date of Birth / /  11. Member Gender Female Male  12. Member ID or 
SSN (Provide SSN only if member ID is not available.)  
SECTION 2 (Please read instructions on the back of this form for how to complete 
this section.)  
13. Type of Status Change Admit Discharge Both admit and discharge  15. Admitted 
From Home/community Hospital Nursing facility Rest home  16. Admission Date / /  
17. Discharge Date / /  
14. Type of Bed Nursing facility Chronic/Rehab  
18. Discharge Reason Discharged to Home/community Discharged to a rest home 
Other (explain): Discharged to a hospital Left against medical advice Discharged 
to a long-term-care facility Deceased. Date of death: / /  
SECTION 3 (Please read instructions on the back of this form for how to complete 
this section.)  
19. MassHealth Requested Payment Date / /  20. Reason for MassHealth Requested 
Payment Date  
21. Length of Stay for Nursing Facility Services Short-term (six months or less) 
More than six months Short-term-care stay terminated  22. Clinical Eligibility 
for Nursing Facility Services Approved Effective date of decision: Approved — 
short term Denied / /  
Complete Items 23, 24, 25 only if member’s expected stay is six months or less.  
23. Certification of Short Term Stay. I certify that the above-named       
member’s expected length of stay is ____________________ .  24. Physician’s 
Signature  25. Date / /  
26. Public Rate Amount $  27. Private Rate Amount $  28. Medicare Upon 
Admission? Yes     No  29. Medicare End Date / /  
30. Does member have managed care organization (MCO), Program for All-Inclusive 
Care for the Elderly (PACE), or Senior Care Options (SCO) coverage? Yes No  31. 
MCO End Date (N/A for SCO/PACE) / /  
32. Is the nursing facility clinical eligibility determination form attached? 
Yes      No  33. For new admission, is Level 1 OBRA/PASARR form attached? Yes      
No  
34. Signature of authorized representative completing the SC-1 form.  35. Date / 
/  

SC-1 (Rev. 05/09) 
SEE REVERSE SIDE FOR INSTRUCTIONS. 
INSTRUCTIONS FOR COMPLETING THE SC-1 FORM (PLEASE PRINT OR TYPE.)  
Below are instructions for specific fields. All other fields are self-
explanatory. For all items with check boxes, please make sure you check one box. 
As noted below, some fields are required to be completed.  
SECTION 1  
Items 1 through 12 are required to be completed on all SC-1 forms.  
Item 1  Provider ID/Service Location  Enter the nine-digit provider ID followed 
by the one-character location code.  
Item 12  Member ID or SSN  Enter the 12-digit MassHealth member ID number. Enter 
the social security number (SSN) only if member ID is not available.  
SECTION 2  
Item 13 is required to be completed.   If Item 13 is “Admit,” items 14-16 are 
required to be completed.   If Item 13 is “Discharge,” items 17-18 are required 
to be completed.   If Item 13 is “Both admit and discharge,” items 14-18 are 
required to be completed.  
Item 18  Discharge Reason  Select the reason for discharge. If none of the 
reasons explains the situation clearly, use the other field to explain.  
SECTION 3 
   If Item 13 is “Admit” or “Both admit and discharge,” items 19-22 and 26-33 
are required to be completed. If Item 21 is “Short-term (six months or less),” 
items 23-25 are required to be completed. Items 34-35 are required to be 
completed on all SC-1 forms.  
Item 19  MassHealth Requested Payment Date  Enter the start date for which 
MassHealth payment is requested.  
Item 20  Reason for MassHealth Requested Payment Date  Describe the reason for 
the request date in Item 19 (e.g., Medicare days ended, private pay ended).  
Item 21  Length of Stay for Nursing Facility Services  The nursing facility 
should enter the information as it appears on the clinical eligibility 
determination completed by MassHealth or its agent.  
Item 22  Clinical Eligibility for Nursing Facility Services  The nursing 
facility should enter the information as it appears on the clinical eligibility 
determination completed by MassHealth or its agent. If clinical eligibility for 
MassHealth payment of nursing facility services has been denied, do not submit 
this form as the facility will not be paid.  
Item 26  Public Rate Amount  Enter the public facility rate for this member.  
Item 27  Private Rate Amount  Enter the private facility rate for this member.  
Item 32  Is the nursing facility clinical eligibility determination form 
attached?  Check the “Yes” box if the nursing facility screening notification 
form is attached. Otherwise, check “No.” If the form is not attached, the member 
will not be coded for long-term-care services.  
Item 33  OBRA/PASARR form attached?  For new admissions only, check the “Yes” 
box if Level 1 OBRA/PASARR form is attached to the SC-1 form. Otherwise, select 
“No.”