Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Chronic Disease and Rehabilitation 
Inpatient Hospital Manual 
Subchapter Number and Title 
Table of Contents 
Page 
vi 
Transmittal Letter 
CDR-28 
Date 
12/01/12 

Appendix A. Directory............. A-1 
Appendix B. Enrollment Centers .......................... B-1 
Appendix C. Third-Party-Liability Codes.................................................Appendix D. Supplemental Instructions for Claims with Other Insurance......................... D-1 
Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider 


Preventable Conditions............................................. U-1 
Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions........................ V-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. EVS Codes and Messages .................................... Y-1 
Appendix Z. EPSDT/PPHSD Screening Services Codes .................. Z-1