Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter ADH-24 November 2009 TO: Adult Day Health Providers Participating in MassHealth FROM: Terence G. Dougherty, Interim Medicaid Director RE: Adult Day Health Manual (Revised Service Codes and Descriptions) MassHealth has revised Subchapter 6 of the Adult Day Health Manual to conform with the amended regulations governing payment for adult day health (ADH) services to eligible MassHealth members, effective November 15, 2009 (see TL ADH-23). The amended regulations and service codes and descriptions for 130 CMR 404.000 are available on the MassHealth Web site at www.mass.gov/masshealth. Subchapter 6 contains the service codes and modifiers that ADH providers must use to bill for ADH services provided to members. The revised Subchapter 6 contains per diem service codes for ADH services to members attending the adult day health program for a full day of six hours or more. The revised Subchapter 6 includes a second set of billing codes, in 15 minute increments, which ADH providers must use for ADH services to members attending the adult day health program for less than six hours per day. The service codes and modifiers are not allowed to be interchanged. MassHeath ADH providers are only authorized to use the 15-minute service code for ADH services of less than six hours per day. For ADH services of six hours per day or more, ADH providers must use the per diem service code. These revisions are effective November 15, 2009. If you have any questions about the information in this transmittal letter 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. NEW MATERIAL (The pages listed here contain new or revised language.) Adult Day Health Manual Pages vi, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Adult Day Health Manual Page vi — transmitted by Transmittal Letter ADH-23 Pages 6-1 and 6-2 — transmitted by Transmittal Letter ADH-22 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Adult Day Health Manual Transmittal Letter ADH-24 Date 11/15/09 6. Service Codes and Descriptions Adult Day Health Services Service Codes and Descriptions: Services .................................................................................. 6-1 Service Codes and Descriptions:Transportation Services ........................................................... 6-1 Appendix A. Directory............................................................................................................................. A-1 Appendix B. Enrollment Centers.............................................................................................................. B-1 Appendix C. Third Party Liability Codes................................................................................................. C-1 Appendix D. Dementia Day Services....................................................................................................... D-1 Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules...................... W-1 Appendix X. Family Assistance Copayments and Deductibles............................................................... X-1 Appendix Y. EVS Codes and Messages................................................................................................... Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes ........................................................................ Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Adult Day Health Manual Transmittal Letter ADH-24 Date 11/15/09 601 Service Codes and Descriptions: Adult Day Health Services MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 404.000 and 450.000. An adult day health provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Adult Day Health Manual. Service Code - Modifier Service Description S5102 Day care services, adult; per diem. (Use for adult day health-basic level of care services of six hours or more per day.) S5102-U1 Day care services, adult; per diem. (Use for adult day health-HPP level of care services of six hours or more per day.) S5102-TG Day care services, adult; per diem. (Use for adult day health-complex level of care services of six hours or more per day.) S5100 Day care services, adult; per 15 minutes (Use for adult day health-basic level of care services of less than six hours per day.) S5100-U1 Day care services, adult; per 15 minutes (Use for adult day health-HPP level of care services of less than six hours per day.) S5100-TG Day care services, adult; per 15 minutes (Use for adult day health-complex level of care services of less than six hours per day.) 602 Service Codes and Descriptions: Transportation Services See 130 CMR 404.413. Service Code - Modifier Service Description T2003 Nonemergency transportation; encounter/trip. (Use for transportation furnished on a single date or on consecutive dates. All transportation services must be billed as one-way trips; round trips should be billed as two one-way trips.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Adult Day Health Manual Transmittal Letter ADH-24 Date 11/15/09 This page is reserved.