MassHealth
The Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Office of Medicaid 
www.mass.gov/masshealth


Member’s Name:_________
Member’s MassHealth No.: _________ 
Date of Determination:_________


MassHealth Payment of Nursing-Facility Services

This notice is sent in response to your request for MassHealth authorization for nursing-facility 
services. In order to qualify for nursing-facility services, you must be both clinically and 
financially eligible for these services. This notice is about your clinical eligibility. You will 
receive a separate notice about your financial eligibility.


1. MassHealth Assessments
Assessments to determine clinical eligibility for nursing-facility services are conducted
by_______________________________________Hospital on behalf of MassHealth. A
hospital nurse reviewed your case in accordance with MassHealth regulations at 130 CMR 456.408, 
and has determined the following. To view MassHealth regulations, go to www.mass.gov/masshealth.

You are clinically eligible for nursing-facility services for a short-term stay up to 30 days because 
nursing facility services are medically necessary as required by MassHealth regulations at 
130 CMR 456.409. Your continued clinical eligibility is subject to review. See 130 CMR 456.408.

You are clinically eligible for nursing-facility services because nursing facility services are 
medically necessary as required by MassHealth regulations at 130 CMR 456.409. Your continued clinical 
eligibility is subject to review. See 130 CMR 456.408.

You are not clinically eligible for nursing-facility services because of the following reason.

	Nursing-facility services are not medically necessary, as required by MassHealth regulations 
	at 130 CMR 456.409.

	Nursing-facility services are not medically necessary because your medical needs can be met 
	in the community, and services are available. See 130 CMR 456.408(A)(2).

You are not eligible for nursing-facility services because the Department of Developmental 
Services/Department of Mental Health, in its capacity as the designated Preadmission Screening Resident 
Review (PASRR) authority, has determined that nursing-facility admission is not appropriate for you. 
(Please see page 2 of this notice, as well as the attached PASRR Determination Notice).


NF-AIH-ADM-O (Rev. 05/10)					continued —>


Member Name:
2. Preadmission Screening Resident Review (PASRR) for Mental Illness, Mental Retardation, or 
Developmental Disability

Federal and state laws require that persons suspected of having mental illness, mental retardation, 
or developmental disability be evaluated in order to determine whether their admission to a nursing 
facility is appropriate. Such evaluations are conducted by the Department of Development Disability 
(DDS) or an agent of the Department of Mental Health (DMH), as appropriate. (See regulations at 
42 CFR 483.108, 483.112(a), and 483.114).

In accordance with these regulations, the AIH nurse reviewed your medical needs and the following was 
determined.

There is no indication of mental illness, mental retardation, or developmental disability.

here is an indication of mental illness, mental retardation, or developmental disability, but one of 
the conditions described in 130 CMR 456.410 (C) applies, and therefore your case was not referred to 
DDS/DMH for evaluation.

There is an indication of mental illness, mental retardation, or developmental disability and your 
case was referred to DDS/DMH, as appropriate, for further PASRR evaluation. In accordance with federal 
PASRR regulations, DDS/DMH has issued a PASRR Determination Notice with the following determination.

	Nursing-facility admission is appropriate for you. (Please see attached PASRR Determination 
	Notice).
	
	Nursing-facility admission is not appropriate for you. (Please see attached PASRR Determination 
	Notice).

Date of current PASRR Determination Notice:________________________________________

Acute Inpatient Hospital on behalf of MassHealth _________________________________,RN

3. Appeal Rights

You have the right to appeal this decision, and, if applicable, the attached DDS/DMH PASRR Determination 
Notice. (Please see attached information about your right to appeal through the fair-hearing process.)


OFFICIAL USE ONLY
Date(s):_________________________
ASAP on behalf of MassHealth _____________________________,RN
Print name __________________________,RN
ASAP address __________________________________________