TO:
FROM:
RE:

Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street Boston, MA 02111 www.mass.gov/masshealth
MassHealth
Municipally Based Health Services
Bulletin 12 May 2007

Municipally Based Health Service Providers Participating in MassHealth Tom Dehner, Acting Medicaid Director 
Administrative Activities Claiming and General Payment Conditions for Direct Services

Background

This document provides guidance on:
•	the methodology for local education authorities (LEAs) to determine what proportion of the tuition payments made to out-of-district schools can be attributed to conducting school-based Medicaid administrative activities;
•	the process for submitting amended administrative activity claims (ACCs); and
•	the employment status information that must be included on the Detailed Expenditure report.
This bulletin also reminds providers about the general payment conditions for MassHealth providers.

Clarification of the Methodology for Claiming Tuition Payments to Out-of-District Schools in Administrative Activities Claims

This section provides additional guidance about the methodology for including out-of-district tuition expenditures in an AAC. It is intended to supplement information already provided in the Claiming Manual for School-Based Administrative Activities (the “Claiming Manual”).
As described in the Claiming Manual, LEAs can claim, on a quarterly basis, the portion of tuition expenditures they make to both day and residential out-of-district schools that is attributable to Medicaid administrative activities. To do this, LEAs must first calculate the health-related portion of quarterly day school and residential school tuition. The formulas for calculating the health-related portion of both the quarterly day school tuition and the quarterly residential school tuition are shown on page 33 of the Claiming Manual.

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MassHealth
Municipally Based Health Services
Bulletin 12 May 2007 Page 2

Clarification of the Methodology for Claiming Tuition Payments to Out-of-District Schools in Administrative Activities Claims
(cont.)

The health-related portion of the quarterly day school tuition and the quarterly residential school tuition must be calculated separately within each job position group (01 through 08). Once calculated, the health-related portions of both the day school and the residential program within each job position group are added together. The result is then placed into the appropriate job position group section of the Detailed Expenditure report. (See pages 30 through 32 of the Claiming Manual for examples.)
If no personnel from a particular job position group participate in an LEA’s quarterly time study, then that LEA cannot include costs for the health-related portion for an out-of-district tuition payment for that job position group in the same quarter’s AAC.
Please note that only placements where the LEA retains financial responsibility for a child’s education under the Department of Education’s special education regulations (603 CMR 28.10) qualify as out-of-district placements.

Process for Submitting       This section provides additional guidance on the information
Amended Administrative    that must be included in an amended AAC. All amended AACs
Activities Claims	submitted after July 1, 2007, must be submitted on the LEA’s letterhead
and include:
•	the LEA’s name;
•	the LEA’s provider number;
•	the dates of the quarter during which the administrative activities expenditures were made;
•	the original gross claim amount;
•	the original net claim amount;
•	the amended gross claim amount;
•	the amended net claim amount;
•	the gross claim difference;
•	the net claim difference;
•	the dated signature of an authorized LEA official; and
•	a statement certifying that the AAC for the given quarter represents actual expenses accumulated under the LEA’s provider agreement with the Office of Medicaid, and that the claim amount is solely related to the LEA’s administrative activity agreement with the Office of Medicaid and does not duplicate any federal claims for reimbursement.
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MassHealth
Municipally Based Health Services
Bulletin 12 May 2007 Page 3
Process for Submitting	The new Administrative Activity Claim Quarterly Claim Certification form
Amended Administrative	is attached to this bulletin as Attachment A. Providers may photocopy
Activities Claims	this for their use or may request a supply by sending a written request
(cont.)	by mail or fax to
MassHealth
Attn: Forms Distribution P.O. Box 9118 Hingham, MA 02043 Fax: 617-988-8973
Please Note: In the first paragraph of this form, in the first blank, insert the months and year for the applicable quarter. In the second blank, insert the name of the applicable LEA.
For original claim submissions, LEAs should continue to certify using the sample form provided on page 16 of the Claiming Manual.

Indicating Employment Status on the Detailed Expenditure Report
General Payment Conditions

For AACs for dates of service on or after July 1, 2007, LEAs must indicate on the Detailed Expenditure report whether each individual is an LEA employee or a contracted individual without benefits. Refer to Attachment B of this bulletin for an excerpt from this report.
As a reminder, providers may not seek payment from MassHealth for direct services unless, on the date of service, the provider was participating in MassHealth and the person receiving the services was a MassHealth member. Providers are considered to have begun participating in MassHealth as of the date on which their provider agreement was executed. See MassHealth regulations at 130 CMR 450.231.

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.

Attachment A
Municipally Based Health Services
Bulletin 12 May 2007
Administrative Activity Claim Quarterly Claim Certification
LEA Provider Number: 	
I certify that, to the best of my knowledge, the administrative activity claim (AAC) for the quarter
	 (date range for quarter including months and year) represents actual expenses
accumulated under the 	 (LEA name) provider agreement with the
Office of Medicaid. The claim amount is solely related to our Administrative Activity Agreement with the Office of Medicaid and does not duplicate any federal claims for reimbursement.
Administrative Activity Claim Expenses:
$    	 Original gross claim amount
$    	 Original net claim amount
$    	 Amended gross claim amount
$    	 Amended net claim amount
$     	 Gross claim difference
$     	 Net claim difference

Signature/Title

Date

Muni-AA C-QCC (05/07)

Submit this completed form to:
Center for Health Care Financing—UMMS Attn: Municipal Medicaid Program 100 Century Drive Worcester, MA 01606

Attachment B
Municipally Based Health Services
Bulletin 12 May 2007
Excerpt of Detailed Expenditure Report

STAFF LAST NAME		STAFF FIRST NAME	JOB TYPE	JOB CATEGORY	JOB
POSITION
GROUP
NUMBER	QUARTERLY SALARY
(A)	UNEMPLOYMENT (B)	HEALTH, LIFE, ETC.
(B)	MEDICARE (B)	WC/INJURY PAYMENTS
(B)	PENSION (B)	OTHER (B)	TOTAL	
			Employee	Speech	01	$2,604.00	$2.54	$238.63	$29.23	$11.70	$23.20	$0.00	$2,909.31	
			Employee	Speech	01	$12,636.00	$12.34	$1,157.98	$141.84	$56.79	$112.59	$0.00	$14,117.54	
			Contractor	Speech	01	$6,130.00							$6,130.00	
Materials-Speech													$19.00	
Ch 766-Speech													$1,684.60	
Total Cost Pool						$21,370.00							$24,860.45