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 133
	January 2007


	TO:	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 
has been used by hospitals to facilitate eligibility determinations and 
health-plan enrollment for newborns of MassHealth-eligible women.  The NOB-1 
was revised to support the Commonwealth Care Health Insurance Program, also 
known as Commonwealth Care, which began on October 1, 2006.

Commonwealth Care
Commonwealth Care is a new health-insurance program administered by the 
Commonwealth Health Insurance Connector Authority (the Connector).  
Commonwealth Care is a program that provides subsidies toward the purchase
 of private health insurance on behalf of enrolled Massachusetts residents
 who are not eligible for MassHealth benefits (other than MassHealth 
Limited).  Applicants must have household incomes at or below 300% of the 
federal poverty level (FPL).  Commonwealth Care coverage is not MassHealth, 
but MassHealth is assisting the Connector in eligibility and enrollment 
processing.

Commonwealth Care enrollment is beginning in two phases:  
*	Phase I – Beginning October 1, 2006, enrollment in 
Commonwealth Care is available for eligible adults with family 
incomes at or below 100% of the FPL.
*	Phase II – Beginning January 2007, enrollment in 
Commonwealth Care will be offered to eligible adults with family 
incomes of up to 300% of the FPL.

Managed Care Organizations (MCOs)
At this time, Commonwealth Care coverage for both phases will be available 
exclusively through the following four MassHealth-contracted managed-care 
organizations (MCOs):
*	Boston Medical Center HealthNet Plan
*	Cambridge Health Alliance’s Network Health
*	Neighborhood Health Plan
*	Fallon Community Health Plan

Although the MCOs for MassHealth and Commonwealth Care are the same, 
service areas in which the MCOs operate differ between programs.  
As a result, some members may be able to enroll with an MCO for 
Commonwealth Care in certain service areas that may not be available to 
MassHealth members.

Enrollment Process for a Child Born to a Commonwealth Care Mother
Pregnant woman eligible for MassHealth
Most women enrolled in Commonwealth Care will be eligible for 
MassHealth once they become pregnant.  If a pregnant woman’s eligibility 
for MassHealth has been established before the birth of her child, the 
hospital must follow the regular process for a MassHealth-eligible 
newborn.  In this case, any child born to a woman who is 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.  A newborn of a woman enrolled in a MassHealth MCO is 
enrolled in the mother’s MCO, retroactive to the baby’s date of birth.

Pregnant woman enrolled in Commonwealth Care at time of birth
For a woman enrolled in Commonwealth Care who either is not eligible for 
MassHealth or whose MassHealth eligibility has not been established 
before the birth of her child, a different process will apply.  When data 
about the newborn is entered into the eligibility system, the newborn child 
will be determined eligible for MassHealth Standard or Family Assistance.  
A MassHealth-eligible newborn of a woman enrolled in a Commonwealth 
Care MCO will be retroactively enrolled in the same MCO as the mother, 
as long as the MCO is available to MassHealth members in the service 
area where the mother lives.  If the MCO is not available to MassHealth 
members, no retroactive MCO enrollment will occur, and the newborn will 
receive MassHealth benefits on a fee-for-service basis until a health plan 
has been selected or assigned, if the mother or guardian does not 
voluntarily select a health plan for the newborn.

MassHealth and Commonwealth Care eligibility and enrollment information 
is available by checking the MassHealth Recipient Eligibility Verification System (REVS) system.

Changes to NOB-1 Form
The NOB-1 form has been updated to identify the mother’s health plan as 
either a MassHealth or Commonwealth Care MCO.

Requesting a Supply
Enclosed is a sample of this revised form.  The NOB-1 form is a two-part 
carbonless 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 
		ATTN:  Forms Distribution
		P.O. Box 9118
		Hingham, MA  02043
		Fax:  617-988-8973
	

Use of Old NOB-1	
Hospitals should start using the NOB-1 (Rev. 01/07) immediately.  To 
minimize the impact of this change on MassHealth providers, MassHealth 
will continue to accept the NOB-1 (Rev. 03/05) through February 2007.  
Until the new NOB-1 (Rev. 01/07) is in use, when the mother is enrolled 
in a Commonwealth Care MCO, the hospital should write “Commonwealth Care” 
after the MCO name in the “Mother’s Plan” area of Section 1 of the NOB-1 form.
	

Questions	
If you have any questions about the information in this bulletin, please 
contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry 
to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.

MassHealth
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
(Include 10th digit)

Mother’s Name
Mother’s Address
Mother’s Date of Birth
Mother’s Phone
Casehead RID/SSN (if different)
(Include 10th digit)

Mother’s Plan (if enrolled in a MassHealth or Commonwealth Care MCO):
MassHealth
Commonwealth Care
Boston Medical Center HealthNet Plan (MCO #1803484)
Fallon Community 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’s Name (Last, First, M.I.)
Child’s Date of Birth
(MM/DD/YYYY)
Sex 
Child’s Birth Weight
lb/oz
grams

Child 1:
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)
Start Date
Cat.
Alpha Case No.

Child 2: RID/SSN (Include 10th digit)
Start Date
Cat.
Alpha Case No.

Authorized Signature and Title
Date

SECTION IV (for MCO unit only)

MCO Site ID
If Disenroll, Reason Code
End Date

MCO Site ID
If Disenroll, Reason Code
End Date

Comments:  

NOB-1 (Rev. 01/07)
Original to hospital

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

The MassHealth NOB-1 form is used by hospitals to facilitate eligibility 
determination and health-plan enrollment of newborns born to MassHealth- or 
Commonwealth Care-eligible women.  Any child born to a woman who is 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.  A newborn of a woman who is enrolled in a MassHealth managed care 
organization (MCO) will be retroactively enrolled in the mother’s MCO to the 
baby’s date of birth.  A newborn of a woman who is enrolled in the Primary Care 
Clinician (PCC) Plan or receiving services on a fee-for-service basis is 
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.  A newborn of a woman enrolled in a Commonwealth Care MCO will be 
determined eligible for MassHealth Standard or Family Assistance.  A MassHealth-
eligible newborn will be retroactively enrolled in the same MCO as the mother, 
as long as the MCO is available to MassHealth members in the service area where 
the mother lives.  If the MCO is not available to MassHealth members, no 
retroactive enrollment will occur and the newborn will receive MassHealth 
benefits on a fee-for-service basis until a health-plan selection has been made 
or assigned, if the mother or guardian does not voluntarily select a health plan 
for the newborn.

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. 
• Mother's MCO Information:  If the mother is a MassHealth member, select the 
“MassHealth” box and select the box next to the name of the mother’s MCO.  If 
the mother is a Commonwealth Care  member, select the “Commonwealth Care” box 
and select the box next to the name of the mother’s MCO.

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:  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

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