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 AIH-45 May 2009 TO: Acute Inpatient Hospitals Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Acute Inpatient Hospital Manual (Appendix E) Appendix E of the Acute Inpatient Hospital Manual contains information required from providers for admission screening. This information has been revised, and this transmittal letter issues those changes. The instructions in Appendix E are effective only upon implementation of NewMMIS on May 26, 2009. If you have any questions about 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.) Acute Inpatient Hospital Manual Pages E-1 and E-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Inpatient Hospital Manual Pages E-1 and E-2 – transmitted by Transmittal Letter AIH-41 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix E: Utilization Management Program Page E-1 Acute Inpatient Hospital Manual Transmittal Letter AIH-45 Date 05/26/09 Information Required for Admission Screening The following is a list of information the admitting provider or designee must give the MassHealth Utilization Management contractor when proposing an elective admission. MassHealth may request additional information at any time to clarify the details of any admission. See 130 CMR 450.208 for regulations about admission screening. Refer to Appendix A in your MassHealth provider manual for contact information about the Utilization Management Program. * the member's name and address; * the member's sex; * the member's date of birth; * the member’s MassHealth identification number; * the guardian's name and address, if applicable; * if applicable, the name of the member’s primary care clinician (PCC) and one of the following: ? the telephone number of the PCC; ? the provider number of the PCC; or ? the address of the PCC; * if applicable, whether the PCC has been notified of the proposed admission; * other health-insurance information; * whether the member is being treated as a result of an accident, and if available, the date and type of accident; * the expected or actual dates of admission and expected discharge date; * the name and provider number of the attending physician; * the name of the hospital; * the primary and secondary diagnoses; * the primary and secondary procedures, if applicable; * the ICD-9-CM codes for both the diagnoses and procedures, if available; * CPT codes for procedures when the facility is out of state; * clinical information that supports the medical necessity of the proposed admission and/or procedure; and * other pertinent information the admitting provider has considered in deciding to admit the member. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix E: Utilization Management Program Page E-2 Acute Inpatient Hospital Manual Transmittal Letter AIH-45 Date 05/26/09 This page is reserved.