Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Division of Medical Assistance 
600 Washington Street
Boston, MA 02111


MassHealth 
Acute Inpatient Hospital Bulletin 116 
August 2000 

TO: Acute Inpatient Hospitals Participating in MassHealth 

FROM: Jean C. Sullivan, Acting Commissioner 

RE: Clinical Review of Inpatient Claims 

Introduction

This is to remind acute inpatient hospitals that they must submit inpatient 
claims and medical records to the Division when all the following conditions 
exist: 

• the medical record supports that the member was admitted for non-behavioral-
health medical treatment; 
• the discharge (or principle) diagnosis is a behavioral-health diagnosis; 
and 
• the claim is for a MassHealth member enrolled on the service 
date(s) with the Division’s behavioral health contractor. 

Procedure

A MassHealth clinician will review the record submitted by the hospital. If the 
clinician determines that the claim was for medical treatment, the claim will be 
processed and appear on a MassHealth remittance advice. If the clinician 
determines that the treatment provided was behavioral health, the claim will be 
returned with a letter of explanation. 

A determination that the admission was for medical and not behavioral-health 
treatment is not a guarantee of payment. In order to be paid, the hospital must 
follow all other Division billing requirements 
including, but not limited to, timely submission of claims. In addition, the 
claim may be subject to prepayment and postpayment review in accordance with 130 
CMR 450.209 and 450.235. 

Claim Submission

The claim and accompanying medical record must be sent to: 

Claims Operations Unit – Clinical Review 
Division of Medical Assistance 
600 Washington Street 
Boston, MA 02111 

Questions

If you have any questions about this bulletin, please contact the MassHealth 
Provider Services Department at (617) 628-4141 or 1-800-325-5231.