Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid

600 Washington Street Boston, MA  02111 www.mass.gov/masshealth
                                                                     MassHealth
Acute Inpatient Hospital Bulletin 129
                                                                     April 2005

     TO:       All Acute Inpatient Hospitals Participating in MassHealth
FROM:       Beth Waldman, Medicaid Director 

RE:       Revised Notification of Birth (NOB-1) Form

Background                          MassHealth has revised the Notification of Birth (NOB-1) form.  The NOB-1 form is used by hospitals on behalf of MassHealth members to facilitate eligibility determination and health plan enrollment of newborns of MassHealth-eligible women.

Any child born to a woman eligible for MassHealth Standard or Limited is automatically eligible for MassHealth Standard for one year from the date of birth if the child continues to live with the mother.  Newborns of women enrolled in a MassHealth Managed Care Organization (MCO) are retroactively enrolled in the mother’s MCO to the baby’s date of birth.

Changes to NOB-1 Form     The NOB-1 form has been updated to simplify the enrollment of MassHealth-eligible newborns.  Previously, NOB-1 forms for babies born to MassHealth MCO-enrolled mothers could be completed by either the hospital or by the MCO.  Effective immediately, all NOB-1 forms are to be completed by the hospital.  All hospitals should complete this form when a child is born to a MassHealth-enrolled woman.  Previously, each newborn had to be documented on a separate NOB-1 form.  The revised NOB-1 form now includes room for up to two children per MassHealth-eligible woman.  If there are more than two children born to a MassHealth-eligible woman, please use an additional form.  Please mail both copies of the form to:

                      MassHealth Enrollment Center
                      ATTN: NOB Unit
300 Ocean Avenue, Suite 4000
                      Revere, MA  02151

Please mail completed NOB-1 forms on a daily basis, as delays may result in the delay of payment for services rendered.

   (continued on back)

MassHealth
Acute Inpatient Hospital
Bulletin 129
April 2005
Page 2

Requesting a Supply            Enclosed is a sample of this revised form.  The NOB-1 form is a carbon copy form and is not available electronically.  Requests for
additional supplies of this form must be submitted in writing, and can be mailed or faxed to:

MassHealth Forms Distribution
                      P.O. Box 9101
Somerville, MA  02145
                      Fax: 617-576-4087
Fax: 703-917-4937

Use of Old Form                   To minimize the impact of this change on MassHealth providers, MassHealth will continue to accept the previous version of the NOB-1 form through May 31, 2005.

Questions                              If you have any questions about the information in this bulletin, please call
MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.

The Commonwealth of Massachusetts
Executive Office of Health and Human Services

Hospital Name

Hospital Address

Hospital Telephone No.

NOTIFICATION OF BIRTH

Send both copies to:   MassHealth Enrollment Center, ATTN: NOB Unit, 300 Ocean Avenue, Suite 4000, Revere, MA 02151

Hospital should complete Section I and Section II. SECTION I:  Mother’s Information

Mother’s RID/SSN

Casehead RID/SSN (if different)

(Include 10th digit)

(Include 10th digit)

Mother’s Name

Mother’s Address

Mother’s Date of Birth                           Mother’s Phone

Mother’s Plan (if enrolled in a MassHealth MCO): Boston Medical Center HealthNet Plan
(MCO #1803484)
Fallon Health Plan  (MCO #1801171) Neighborhood Health Plan (MCO #1801562) Network Health Plan (MCO #1803441)

SECTION II:  Child’s Information (Please Note:  You must enter child’s birthweight and indicate race)

Child 1:

Child’s Name (Last, First, M.I.)

Child’s Date of Birth
(MM/DD/YYYY)               Sex

Child’ Birth Weight lb/oz                        grams

Child 2:

Race Code:

1-American Indian              2-Asian                                                          3-Black, not of Hispanic origin

4-Hispanic                           5-White, not of Hispanic origin                    9-Race unknown or unreported

Has an application for the child’s social security number been made through the hospital?             Yes               No

I certify that the above-named child was born to the mother listed above:
Signature and Title                                                      Date

SECTION III (for MassHealth use only)

Child 1: RID/SSN (Include 10th digit)

Alpha Case No.

Start
 Date

  /   /

 Cat.

Child 2: RID/SSN (Include 10th digit)

Alpha Case No.

Start
 Date

  /   /

 Cat.

Authorized Signature and Title                                                                             Date

SECTION IV (for MCO unit only)

  MCO Site ID                             If Disenroll, Reason Code

Comments:

End
 Date                 MCO Site ID
  /   /

If Disenroll, Reason Code

End
 Date
  /   /

NOB-1 (Rev. 03/05)

Original to hospital

Purpose of MassHealth Notification of Birth (NOB-1) Form

The MassHealth NOB-1 form is used by hospitals on behalf of MassHealth members to facilitate eligibility determination and health plan enrollment of newborns born to MassHealth eligible women. Any child born to a woman eligible for MassHealth Standard or Limited is automatically eligible for MassHealth Standard for one year from the date of birth if the child continues to live with the mother. Newborns of women enrolled in a MassHealth Managed Care Organization
(MCO) will be retroactively enrolled in the mother’s MCO to the baby’s date of birth. Newborns of women enrolled in the Primary Care Clinician (PCC) Plan or receiving services on a fee-for-service basis are provided MassHealth benefits on a fee-for-service basis until a health plan selection is made or assigned, if the member does not voluntarily select a health plan.

The NOB-1 form is used to:
•     Process newborn MassHealth eligibility
•     Provide hospitals with a mechanism for receiving newborn temporary Recipient Identification Numbers (RID) in order to submit claims
•     Enroll newborns into MCOs
•     Track Federal government required birthweight and race information

Instructions For Completing The NOB-1 Form

SECTION I: Mother’s Information

•     Mother’s  RID/SSN: Enter the nine-digit RID of the mother. Please include the 10th digit in the separate box.
•     Casehead RID/SSN (if different): If the casehead is someone other than the mother, for example, a spouse or grandparent, please enter the RID of that person. Please include the 10th  digit in the separate box.
•     Mother's Name, Address, Date of Birth, and Phone: Enter the name, address, date of birth, and phone number of the child's mother.
•     MassHealth MCO Information: If the mother is enrolled in a MassHealth Managed Care Organization (MCO), please select the box next to the MCO name.

SECTION II: Child’s Information

•     Child's Name: Enter the child's last name, first name, and middle initial. If the child is unnamed, enter the last name, followed by "Baby Boy," or "Baby Girl." In the case of same-sex multiple births as yet unnamed, add a letter suffix to the child's name, for example, "Smith, Baby Boy A" and "Smith, Baby Boy B."
•     Child's Date of Birth: Enter the child's date of birth, using an MM/DD/YYYY format.
•     Sex: Enter F for female or M for male.
•     Birthweight: Use the appropriate box to enter the child's birthweight in pounds and ounces or in grams.
•     Race: Select the child’s race.
•     Social Security Application: Indicate if an application for the child's social security number has been made through the hospital.
•     Certification: Please sign and date the form. Please include your title. The director of medical records or patient accounts manager of the hospital must sign the NOB-1.

Mailing the NOB-1 Form

•     Please use original NOB-1 forms only. Photocopies will not be accepted.
•     Please mail both copies to: MassHealth Enrollment Center, Attn: NOB Unit, 300 Ocean Avenue, Suite 4000, Revere, MA. 02151.