Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
	MassHealth
	Chronic Disease and 
	Rehabilitation Hospital Bulletin 83
	January 2003

	TO:	Chronic Disease and Rehabilitation Hospitals Participating in MassHealth

	FROM:	Wendy E. Warring, Commissioner

	RE:	Changes in Clinical Assessment Forms

Background	The Division determines clinical eligibility for MassHealth long-term-care services based upon documentation submitted by the provider.  The Long Term Care Assessment form has been replaced by two new forms in order to facilitate communication between providers and the Division.  

New Forms	Attached to this bulletin are copies of the two new forms required for approving referrals for long-term-care services, including, but not limited to, nursing-facility and adult-day-health services.  
•	Request for Services (RFS-1) (formerly called the MassHealth Long Term Care Assessment form)
•	Minimum Data Set – Home Care (MDS-HC)

	Chronic disease and rehabilitation hospitals must begin using these new forms by February 1, 2003.  Please discard all previous versions of the Long Term Care Assessment form.

Who May Complete	The MDS-HC must be completed by an assessment coordinator.  The
the MDS-HC	assessment coordinator must be a registered nurse who certifies the accuracy and completeness of the MDS-HC.

	The following sections of the MDS-HC may be completed by a licensed social worker (LSW, LCSW, or LICSW).  
	AA – Name and Identification Numbers
	BB – Personal Items
	CC – Referral Items
	B – Cognitive Patterns
	C – Communication/Hearing Patterns
	E – Mood and Behavior Patterns
	F – Social Functioning
	G – Informal Support Services
	O – Environmental Assessment
	
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Who May Complete	Each person who completes a portion of the MDS-HC must sign and
the MDS-HC 	certify the sections he or she completes in Section R – Assessment
(cont.)	Information (Other Signatures, Title, Sections, Date).

Qualifications for	The registered nurse or social worker must be licensed by the  
Completing the Forms	Massachusetts Board of Registration.

ICD-9-CM Codes	The MDS-HC assessment requires the use of the ICD-9-CM codes for medical diagnoses.

Trainings	The Division holds periodic trainings for providers.  You will receive notice of trainings when they are scheduled.

Supplies of the Forms	You may photocopy the forms as needed.  To obtain supplies of the forms, use the information below to mail or fax your request.  Include your provider number, address, telephone number, the exact title of the form, and the desired quantity.

	MassHealth Forms Distribution
	P.O. Box 9101
	Somerville, MA  02145
	Fax:  703-917-4087

Questions	If you have any questions about this bulletin, please contact MassHealth Provider Services at 617-628-4141 or 1‑800‑325-5231.