Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Acute Inpatient Hospital Manual 
Subchapter Number and Title 
Table of Contents 
Page 
vi 
Transmittal Letter 
AIH-47 
Date 
01/01/12 

Appendix A. 
Directory.......................................................................
............................................ A-1 
Appendix B. Enrollment 
Centers.........................................................................
.......................... B-1 
Appendix C. Third-Party-Liability Codes 
................................................................................
..... C-1 
Appendix E. Information Required for the Utilization Management Program 
............................. E-1 
Appendix F. Admission Guidelines 
................................................................................
.............. F-1 
Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity 
Schedules .......... W-1 
Appendix X. Family Assistance Copayments and 
Deductibles..................................................... X-1 
Appendix Y. REVS Codes/Messages 
................................................................................
............ Y-1 
Appendix Z. EPSDT Services Laboratory 
Codes.......................................................................... 
Z-1