Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
Appendix D: Utilization Management Program 
 Page 
D-1 

 
Acute Outpatient Hospital Manual 
 Transmittal Letter 
AOH-21 
 Date 
05/26/09 
 


 
Information Required for Admission Screening 
 
The following 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. Refer to Appendix A in your MassHealth provider manual for contact information about the Utilization Management Program.  
•
 the member's name and address;  


•
 the member's sex; 


•
 the member's date of birth; 


•
 the member’s MassHealth identification number; 


•
 the guardian's name and address, if applicable; 


•
 if applicable, the name of the member’s primary care clinician (PCC) and one of the following: 



 the telephone number of the PCC; 



 the provider number of the PCC; or 



 the address of the PCC; 



•
 if applicable, whether the PCC has been notified of the proposed admission; 


•
 other health-insurance information; 


•
 whether the member is being treated as a result of an accident, and if available, the date and type of accident; 


•
 the expected or actual dates of admission and expected discharge date; 


•
 the name and provider number of the attending physician; 


•
 the name of the hospital; 


•
 the primary and secondary diagnoses; 


•
 the primary and secondary procedures, if applicable; 


•
 the ICD-9-CM codes for both the diagnoses and procedures, if available; 


•
 CPT codes for procedures when the facility is out of state; 


•
 clinical information that supports the medical necessity of the proposed admission and/or procedure; and 


•
 other pertinent information the admitting provider has considered in deciding to admit the member. 



 
 
  
 
Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
Appendix D: Utilization Management Program 
 Page 
D-2 
 
Acute Outpatient Hospital Manual 
 Transmittal Letter 
AOH-21 
 Date 
05/26/09 
 


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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