Part 4. Required Forms and Documentation
For certain services, MassHealth requires other forms and documentation. Some services require you 
to submit a specific attachment with your claim, while others may require you to just keep the 
documentation in the member’s medical record. See the applicable program regulations in your 
MassHealth provider manual for specific report requirements. You can access the provider manuals 
from the Provider Library on the MassHealth Web site. Go to www.mass.gov/masshealth. Click on 
MassHealth Regulations and Other Publications, then on Provider Library.
Types of Attachments
The following types of attachments may be required for your claims. 
General Report or Supplier's Invoice
*	You must submit a general written report or a discharge summary when the service code 
description stipulates “with report only,” individual consideration (I.C.), or when you use a service 
code for an unlisted procedure. Consult the applicable program regulations in your MassHealth 
provider manual for additional information. 
*	If the I.C. service is a laboratory or radiology service, and all the required information is entered 
on the claim form in the space for description, you do not need to attach additional documentation.
*	Claims for medical supplies, medications, or injectables provided outside a pharmacy may require 
a supplier’s invoice as the attachment.
Operative Report 
For surgery service codes designated I.C., you must submit operative notes in addition to the claim.
MassHealth Forms
When applicable, you may also be required to submit other attachments (e.g., Certification for Payable 
Abortion or Sterilization Consent Form). The forms may be downloaded from the Provider Library at 
www.mass.gov/masshealth. 


Other Forms
You may be required to complete and submit certain other forms before providing a service. Refer to 
other sections of your MassHealth provider manual for additional required forms and reports that are 
specific to the services you provide. These forms may include
*	prior authorization and supplemental authorization forms;
*	medical necessity forms; or
*	other admission, election, or screening forms.
Obtaining Forms
You may download provider forms from the MassHealth Web site at www.mass.gov/masshealth, by 
clicking on the MassHealth Provider Forms link. You can also request supplies of these forms from 
the appropriate address listed in Appendix A of this manual.

Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
5. Administrative and Billing 
Instructions
Page
5.4-1
All Provider Manuals
Transmittal Letter
ALL-165
Date
05/26/09