Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Division of Medical Assistance 

600 Washington Street 
Boston, MA 02111


 MassHealth 
Home Health Agency Bulletin 38 
October 2000

 TO: Home Health Agencies Participating in MassHealth 

FROM: Wendy E. Warring, Commissioner 

RE: Revised MassHealth Reporting Form for Continuous Skilled Nursing 

Background 
The Division has renamed and revised the MassHealth Adjustment Form 
for Continuous Skilled Nursing. The form has been renamed the 
MassHealth Reporting Form for Unused, Authorized Continuous Skilled 
Nursing Services. The form has been revised to simplify the process of 
reporting unused, authorized hours to the Division. 

Reporting 
The Division would like to clarify that the primary provider, either the 

Unused Hours 
home health agency or the independent nurse, is responsible for 
reporting any unused, authorized hours, including those authorized for 
any co-vendor. Therefore, the co-vendor must report to the primary 
provider, either the home health agency or the independent nurse any 
unused, authorized hours. 

Categories of Unused hours have been separated into three categories that 
indicate 
Unused Hours why the authorized hours were not used. 

• 
No nursing staff - if no nursing staff was available, the primary 
provider must document, in the space provided on the form, attempts 
to co-vend. 
• 
Hospitalization - use this to indicate that the member was an inpatient 
at an acute or chronic-disease or rehabilitation hospital. 
• 
Family preference – use this to indicate that unused hours were due 
to family involvement; for example, the family was on vacation or the 
regular nurse was unavailable and the family did not want a 
replacement. 
Monthly Reporting The Division requires monthly reporting of unused, authorized 
hours. The 
Requirement form has been revised to allow the reporting of unused hours for two 
prior 
authorization periods that fall within the same month for the same member. 




MassHealth 
Home Health Agency Bulletin 38 
October 2000 
Page 2 

Elimination of 
Section C has been eliminated from the form. When the provider makes 

Section C 
a telephone request to increase or decrease the hours in a current 
prior authorization, the Division will make a decision based on the 
information supplied by the provider, advise the provider of the decision, 
and send notification in writing to the provider and the member. The 
provider no longer is required to submit the adjustment in writing to the 
Division. 

Effective Date Providers must begin using this revised form on November 1, 2000. 

Supplies 
A copy of the revised form is attached to this bulletin. Providers may 
photocopy the form for their own supplies or write or send a fax to 
MassHealth Forms Distribution. Include your provider number and 
specify the name of the form (PDN-002 Rev. 10/00) and the quantity. 

UNISYS 
ATTN: MassHealth Forms Distribution 

P.O. Box 9101 
Somerville, MA 02145 
Fax: (617) 576-4087 
Questions 
If you have any questions about this bulletin, please contact the 
MassHealth Provider Services Department at (617) 628-4141 or 
1-800-325-5231.