Appendices for All Provider Manuals

MassHealth updates the generic appendices contained in all provider manuals (Appendices A, B, C, U, V, W, X, Y, and Z) as needed. Paper copies of these appendices are not mailed automatically to providers, but can be requested by calling, faxing, e-mailing, or mailing a request to:

Phone: 1-800-841-2900
Fax: 617-988-8973
E-mail: publications@mahealth.net
Mailing address:
MassHealth Publications
P.O. Box 9118
Hingham, MA 02043

  • Appendix A: Directory (PDF) pdf format of    appx-a-all.pdf  txt format of appx-a-all.txt
    This appendix contains the names, addresses, and telephone numbers of units, agencies, and contractors that you may need to contact in the course of doing business with MassHealth.
  • Appendix B: Enrollment Centers (PDF) pdf format of    appx-b-all.pdf  rtf format of appx-b-all.rtf file size 1MB
    This appendix lists for each of the four regional MassHealth Enrollment Centers the address, telephone and fax numbers, responsibilities, and towns they serve.
  • Appendix C: Third-Party-Liability Codes (PDF) pdf format of    appx-c-all.pdf  txt format of appx-c-all.txt
    This appendix contains lists of third-party-liability (TPL) coverage-type codes and carrier codes to help you identify a member's other insurance. The MassHealth Recipient Eligibility Verification System (REVS) reports TPL coverage-type and carrier codes for all applicable insurance coverage listed on file for each member.
  • Appendix U: DPH-Desginated Serious Reportable Events That Are Not Provider Preventable Conditions pdf format of    appx-u.pdf  txt format of appx-u.txt
    This appendix lists events that are designated by the Massachusetts Department of Public Health (DPH) as “Serious Reportable Events (SREs)” in accordance with 105 CMR 130.332 (or 105 CMR 140.308, as applicable) that are not considered “Provider Preventable Conditions” (PPCs) under MassHealth. These SREs are subject to applicable MassHealth provisions on “Serious Reportable Events” set forth, in the case of DPH-licensed hospital providers, in the hospital’s agreement with MassHealth governing payment for services, or in the case of freestanding ambulatory surgery centers, in Transmittal Letter FAS-25.
  • Appendix V: MassHealth Billing Instructions for Provider Preventable Contitions pdf format of    appx-v.pdf  txt format of appx-v.txt
    This appendix describes the MassHealth billing instructions for Provider Preventable Conditions (PPCs), as they apply to providers. The appendix is subdivided into three parts: (1) billing instructions for PPCs for inpatient hospitals; (2) billing instructions for PPCs for outpatient hospitals and freestanding ambulatory surgery centers; and (3) billing instructions for PPCs for all other MassHealth providers.
  • Appendix W: EPSDT Services Medical and Dental Protocols and Periodicity Schedules (PDF) pdf format of    appx-w-all.pdf  rtf format of appx-w-all.rtf
    This appendix lists the services required under the Early and Periodic Screening, Diagnosis and Treatment (EPDST) Program, and the ages at which those services must be provided.
  • Appendix X: Family Assistance Copayments and Deductibles (PDF) pdf format of    appx-x-all.pdf  rtf format of appx-x-all.rtf
    MassHealth will pay for certain copayments, deductibles, and coinsurance amounts for certain MassHealth Family Assistance members under age 19. This appendix describes who is eligible, the types of copayments, deductibles, and coinsurance amounts that are covered, and how to bill for these services.
  • Appendix Y: EVS Codes and Messages (PDF) pdf format of    appx-y-all.pdf  doc format of appx-y-all.doc
    This appendix lists the active Eligibility Verification System (REVS) codes and their respective service restriction messages.
  • Appendix Z: EPSDT/PPHSD Screening Services Codes (PDF) pdf format of    appx-z-all.pdf  rtf format of appx-z-all.rtf
    This appendix lists the services that are payable in addition to the EPSDT periodic visit when they are performed and interpreted in the office of the provider who furnished the visit.

Provider-Specific Appendices

Updates to provider-specific manual appendices are automatically mailed to relevant providers.

Acute Inpatient Hospitals

  • Appendix D: Supplemental Instructions for Claims with Other Insurance (PDF) pdf format of    appx-d-aih.pdf  doc format of appx-d-aih.doc
    This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04. 
  • Appendix E: Information Required for the Utilization Management Program (PDF pdf format of    appx-e-aih.pdf    ) pdf format of    appx-e-aih.pdf  txt format of appx-e-aih.txt
    This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission. It also provides contact information for the MassHealth Utilization Management Program contractor.

Acute Outpatient Hospitals

  • Appendix D: Utilization Management Program (PDF) pdf format of    appx-d-aoh.pdf  txt format of appx-d-aoh.txt
    This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission. It also provides contact information for the MassHealth Utilization Management Program contractor.

  • Appendix E: Admission Guidelines (PDF) pdf format of    appx-e-aoh.pdf  txt format of appx-e-aoh.txt
    This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

  • Appendix F: Revenue Codes (PDF) pdf format of    appx-f-aoh.pdf  txt format of appx-f-aoh.txt
    This appendix contains a crosswalk of revenue codes and related HCPCS codes.

Adult Day Health Manual

Chronic Disease and Rehabilitation Inpatient Hospital Manual

  • Appendix D: Supplemental Instructions for Claims with Other Insurance (PDF) pdf format of    appx-d-cdr.pdf  doc format of appx-d-cdr.doc
    This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

Community Health Center Manual

  • Appendix E: Utilization Management Program (PDF pdf format of    appx-e-chc.pdf    ) pdf format of    appx-e-chc.pdf  txt format of appx-e-chc.txt
    This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission. It also provides contact information for the MassHealth Utilization Management Program contractor.


Dental Manual

  •   Appendix G: Utilization Management Program pdf format of    Appendix G: Utilization Management Program  doc format of Appendix G: Utilization Management Program
    This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission. It also provides contact information for the MassHealth Utilization Management Program contractor.

Freestanding Ambulatory Surgery Center Manual

Home Health Agency Manual

  • Appendix D: Supplemental Instructions for TPL Exceptions (PDF) pdf format of    appx-d-hha.pdf  doc format of appx-d-hha.doc
    This appendix contains billing instructions for submitting 837I and 837P transactions, paper claims, and direct data entry (DDE) claims for members who have Medicare or commercial insurance, and whose services are determined not covered by the primary insurer. This appendix lists the exceptions that need to be considered when billing MassHealth, for members who have Medicare or commercial insurance. These are specific MassHealth billing instructions that are not described in the HIPAA implementation guides for the 837I and 837P transactions, in the 837I and 837P companion guides, or in the billing guides for the UB-04 or CMS-1500 claim forms.
  • Appendix E: Criteria for Provider Liability pdf format of    appx-e-hha  txt format of appx-e-hha
    This appendix explains the review criteria that MassHealth uses to determine home health agency liability for invalid home health advanced beneficiary (HHABN) notices.

Mental Health Center

Nursing Facility Manual

  • Appendix D: Specification for Electronic Submission of MMQ (PDF) pdf format of    appx-d-nur.pdf  txt format of appx-d-nur.txt
    This appendix provides specifications for submitting Management Minutes Questionnaire (MMQ) information electronically.
  • Appendix E: Instructions for Completing MMQ (PDF pdf format of    appx-e-nur.pdf    ) pdf format of    appx-e-nur.pdf  txt format of appx-e-nur.txt
    This appendix provides instructions for completing initial and semiannual Management Minutes Questionnaires (MMQ).
  • Appendix F: Unit-Dose Drugs (PDF) pdf format of    appx-f-nur.pdf  txt format of appx-f-nur.txt
    This appendix lists the unit-dose packaged drugs that a nursing facility must return to the dispensing pharmacy in accordance with 130 CMR 456.621, when the use of the drug for the member is discontinued.
  • Appendix G: Supplemental Instructions for TPL Exceptions (PDF) pdf format of    appx-g-nf.pdf  doc format of appx-g-nf.doc
    This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

Pharmacy Manual

  • Appendix D: Unit-Dose Drugs (PDF pdf format of    appx-d-phm.pdf    ) pdf format of    appx-d-phm.pdf  rtf format of appx-d-phm.rtf
    This appendix lists the unit-dose-packaged drugs that the dispensing pharmacy must credit to MassHealth when they have been dispensed to a MassHealth member in a nursing facility and have been returned by the nursing facility in accordance with 130 CMR 406.446.

Physician Manual

  • Appendix E: Admission Guidelines (PDF pdf format of    appx-e-phy.pdf    ) pdf format of    appx-e-phy.pdf  rtf format of appx-e-phy.rtf
    This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.
  • Appendix I: Utilization Management Program (PDF) pdf format of    appx-i-phy.pdf  txt format of appx-i-phy.txt
    This appendix 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.

  • Appendix K: Teaching Physicians (PDF) pdf format of    app-k-phy.pdf  txt format of app-k-phy.txt
    This appendix contains service codes for which a teaching physician may bill MassHealth even though he or she is not physically present for the key portions of the service. Note: This exception does not apply in certain circumstances if the teaching physician is also a primary care clinician in the Primary Care Clinician Plan. (See 130 CMR 450.275.)

Podiatrist Manual

  • Appendix E: Utilization Management Program (PDF) pdf format of    appx-e-pod.pdf  txt format of appx-e-pod.txt
    This appendix 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.
  • Appendix F: Admission Guidelines (PDF) pdf format of    appx-f-pod.pdf  txt format of appx-f-pod.txt
    This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Psychiatric Inpatient Hospital

  • Appendix D: Supplemental Instructions for TPL Exceptions (PDF) pdf format of    appx-d-pih.pdf  doc format of appx-d-pih.doc
    This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

Sterilization Clinic Manual

  • Appendix E: Utilization Management Program (PDF) pdf format of    appx-e-str.pdf  txt format of appx-e-str.txt
    This appendix 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.

This information is provided by MassHealth.