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 137 September 2009 TO: Acute Inpatient Hospitals Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Preadmission Screening and Postpayment Review Preadmission Screening Admission screening, also known as preadmission screening (PAS), must Reminder be obtained for all elective inpatient admissions. MassHealth will deny payment if providers do not comply with this requirement. Detailed requirements and specific exceptions are identified in the regulations130 CMR 415.405, 415.414, 450.207, and 450.208. PAS should not be confused with Prior Authorization (PA). The Utilization Management program does not waive or replace any other MassHealth requirements, including PA. A specific procedure or treatment may separately require PA. Postpayment Review In NewMMIS, any claim that is disallowed after Postpayment Review by Claims in NewMMIS the MassHealth contractor for the Acute Hospital Utilization Management Program (currently Masspro) will be voided by MassHealth. The advantage of this method is that a provider will be able to directly see the void of the originally submitted claim. There will be no need to establish separate recoupment accounts for voided claims. This void process will allow for the clean rebill of a claim that was a previously paid as an inpatient claim and was subsequently voided because the services should have been provided as outpatient services. This is a change for providers in cases of partial denials (for example, when a claim is submitted for the standard payment amount per discharge (SPAD) for inpatient services and a transfer per diem (TPD) is allowed, or a line item of an outpatient claim is denied, but the remainder of the services on the claim is allowed). (continued on next page) Provider Process for Following a Postpayment Review claims denial for any of the reasons Postpayment Rebills discussed above, providers may rebill MassHealth for • outpatient services following the denial of a claim for inpatient services; • TPD allowed when a SPAD is billed; or • the lesser amount of outpatient services allowed than initially billed. To rebill MassHealth, providers must submit the claim to be rebilled, also known as a “void/replace” claim (type of bill (TOB) 117) with the former transaction control number/internal control number (TCN/ICN) indicated to the address below. Providers are reminded to review 130 CMR 415.417, the regulation concerning Notification of Denial, Reconsideration, and Appeals. NewMMIS Changes All rebilled claims, whether for inpatient or outpatient services, must be Affecting Requesting submitted in writing along with a copy of the denial letter to: Reimbursement Kathleen McKeown Utilization Management/MassHealth 600 Washington Street CTC Room 310 Boston, MA 02111 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.