Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth
	MassHealth
	Rest Home Bulletin 33
	May 2009




	TO:	Rest Homes

	FROM:	Tom Dehner, Medicaid Director

	RE:	New Status Change for Residents in a Rest Home (SC-1-RH) Form 


Background	In preparation for the implementation of NewMMIS, a new form, the 
Status Change for Residents in a Rest Home (SC-1-RH) Form, has been 
developed to be used only by rest homes.

	Many fields on this form are the same as those on the Status Change for 
Members in a Nursing Facility or Chronic Disease and Rehabilitation 
Inpatient Hospital (SC-1) Form, which has been revised for NewMMIS.


Sections on the SC-1-RH 	There are three sections on the form, as described below.
Form
	Section 1 contains fields that gather general information about the rest 
home. 

	Section 2 contains fields for the type of status change being requested, 
where the member is being admitted from, the admission and discharge 
dates, and discharge reason.

	Section 3 contains the requested payment date, along with the signature 
and date fields.

	Instructions are included for how to complete specific fields on the form. 
All other fields are self-explanatory.
	
(continued on next page)



Using the New SC-1-RH 
Form
You can begin using the SC-1-RH form starting May 26, 2009. 
The SC-1 form can be downloaded from the MassHealth Web site 
at www.mass.gov/masshealth. Request for paper copies of this 
form must be submitted in writing and faxed to 617-988-8973 or 
mailed to the following address.
MassHealth 
ATTN: Forms distribution 
P.O. Box 9118 
Hingham, MA 02043
A sample of the new SC-1-RH form is attached.
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.
 


			MassHealth
			Rest Home Bulletin 33
			May 2009
			Page 2








Status Change for Residents in a Rest Home 
(Admission or Discharge of SSI Recipients) 
SECTION 1  
1. Rest Home ID/Service Location  2. Name of Rest Home  3. Telephone No. of Rest Home  
4. Address of Rest Home  
5. Resident Last Name  6. Resident First Name  7. Middle Initial  
8. Resident Home Address  
9. Resident Date of Birth / /  10. Resident Gender Female Male  11. Member ID or SSN (Provide SSN only if member ID is not available.)  
SECTION 2  
12. Type of Status Change Admit Discharge Both admit and discharge  13. Admitted From Home/community Hospital Nursing facility Rest home  14. Admission Date / /  
15. Discharge Date / /  
16. Discharge Reason Discharged to home/community Discharged to a rest home Other (explain): Discharged to a hospital Left against medical advice Discharged to a long-term-care facility Deceased. Date of death: / /  
SECTION 3  
17. Requested Payment Date / /  
18. Signature of authorized representative completing the SC-1-RH form.  19. Date / /  

INSTRUCTIONS FOR COMPLETING THE SC-1-RH FORM (PLEASE PRINT OR TYPE.)  Below are instructions for specific fields. All other fields are self-explanatory. For all items with check boxes, please make sure you check one box.  
SECTION 1  
Item 1  Rest Home ID/Service Location  Enter the nine-digit provider ID followed by the one-character location code.  
Item 11  Member ID or SSN  Enter the 12-digit MassHealth member ID number. Enter the social security number (SSN) only if member ID is not available.  
SECTION 2  
Item 16  Discharge Reason  Includes home/community, hospital, long-term-care facility, rest home, or left against medical advice. If selecting deceased, enter the date of death. If reason is any other, explain the reason in the space provided.  
SECTION 3  
Item 17  Requested Payment Date  Enter the start date for which payment is requested.  

SC-1-RH (05/09)