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 136 May 2009 To: Acute Inpatient Hospitals Participating in MassHealth From: Tom Dehner, Medicaid Director RE: Revised Notification of Birth (NOB-1) Form Background The NOB-1 form is used by hospitals to facilitate eligibility determinations and health-plan enrollment for newborns of MassHealth and Commonwealth Care-eligible women. The form has been revised to support changes as a result of the implementation of NewMMIS on May 26, 2009. Changes to the NOB-1 Form The following changes have been made to the NOB-1 form. * The timeline for submission of the form has been changed from 60 days from the newborn’s date of birth, to 30 days from the newborn’s date of birth. * A new Commonwealth Care-only managed care organization (MCO) called CeltiCare has been added to the current list of health plans, but will be effective beginning July 2009. Please Note: The provider ID/service location for CeltiCare has not yet been finalized. This number will be available soon and will be printed on the NOB-1 form when it is revised again. * The Primary Care Clinician (PCC) Plan has been added to the list of current plans to identify the mother’s health plan. * Recipient ID (RID) is now replaced by member ID, and is now 12 characters instead of 10. * Gestational age has been added to the newborn’s details. * A new race code, 7 (Interracial), has been added. Using the New NOB-1 Form Hospitals must start using the revised NOB-1 (Rev. 04/09) immediately. (continued on next page) Using the Old NOB-1 Form To minimize the impact of the revisions to the form on MassHealth providers, MassHealth will continue to accept the old NOB-1 (Rev. 01/07) through August 2009. However, please note that providers will need to write in missing information (gestational age) if the old form is submitted. Requesting a Supply of the NOB-1 Form The NOB-1 form is a two-part carbonless form and is not available electronically. A sample of the revised form is attached. Requests for additional supplies of this form must be submitted in writing, and can be mailed or faxed to the following address. MassHealth ATTN: Forms Distribution P.O. Box 9118 Hingham, MA 02043 Fax: 617-988-8973 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 All Provider Bulletin 136 May 2009 Page 2 Hospital Name The Commonwealth of Massachusetts Executive Of.ce of Health and Human Services www.mass.gov/masshealth Hospital Address Hospital Telephone No. Noti.cation of Birth Send both copies to: MassHealth Enrollment Center, ATTN: NOB Unit, 300 Ocean Avenue, Suite 4000, Revere, MA 02151. The hospital should complete Sections I and II only. Section II: Child’s Information (Please Note: You must enter child’s birth weight and indicate race.) NOB-1 (Rev. 04/09) Purpose of MassHealth Noti.cation of Birth (NOB-1) Form The NOB-1 form is used to: • process newborn MassHealth eligibility; • provide hospitals with a mechanism for receiving newborn Member ID in order to submit claims; • enroll newborns into MCOs; and • track federal government required birth weight and race information. 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 bene.ts 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 bene.ts 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. Instructions for Completing the NOB-1 Form Section I: Mother’s Information • Mother’s Member ID: Enter the 12-digit member ID of the mother. • Casehead Member ID: If the casehead is someone other than the mother, for example, a spouse or grandparent, please enter the member ID of that person. • Mother’s Name, Address, Date of Birth, and Tel. No.: Enter the name, address, date of birth, and phone number of the child’s mother. • Mother’s Plan: Check the appropriate box to indicate the mother’s plan and/or MCO. Section II: Child’s Information • Child’s Name: Enter the child’s last name, .rst 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 suf. x 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. • Gender: Enter “F” for female or “M” for male. • Birth weight: Enter the child’s birth weight in pounds and ounces or in grams. • Gestational Age: Enter the child’s gestational age. • Race: Check the appropriate box to indicate the child’s race. • Social Security Application: Indicate if an application for the child’s social security number has been made through the hospital. • Certi.cation: 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 Completed 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.