Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Office of Medicaid 
600 Washington Street 
Boston, MA  02111 
www.mass.gov/masshealth 
 

 
 


Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
Appendix E: Utilization Management Program 
 Page 
E-1 
 
Sterilization Clinic Manual 
 Transmittal Letter 
STR-16 
 Date 
05/26/09 
 


 
Information Required for Admission Screening 
 
The following is a list of basic information required for all hospital reviews. Additional information may be 
requested according to the type of review being conducted and in response to the details of any particular 
case. Refer to Appendix A in your MassHealth provider manual for contact information about the Utilization Management Program.  
•
 the recipient's name; 


•
 the recipient's sex; 


•
 the recipient's date of birth; 


•
 the recipient's Medicaid identification number; 


•
 the recipient's address; 


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


•
 if the recipient has a primary care clinician (PCC), the name of the PCC and one of the following is required: 



 the telephone number of the PCC; 



 the provider number of the PCC; or 



 the address of the PCC; 



•
 the expected or actual dates of admission and discharge; 


•
 the number of preoperative days, if applicable; 


•
 the name 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; 


•
 other information relevant to the assessment of the appropriateness of the treatment site; and 


•
 length of stay (for example, available support services and restrictive home environment). 



 
For the concurrent review component, the following information must ALSO be provided. 
•
 relevant clinical and patient-history information; 


•
 a list of the identified or potential barriers to discharge; and 


•
 the name and telephone number of the person responsible for the discharge planning.  



 
  
 
Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
Appendix E: Utilization Management Program 
 Page 
E-2 
 
Sterilization Clinic Manual 
 Transmittal Letter 
STR-16 
 Date 
05/26/09 
 


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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