Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter ADH-22 July 2007 TO: Adult Day Health Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Adult Day Health Manual (Revised Service Codes and Descriptions) This letter describes revisions to service codes and descriptions contained in Subchapter 6 of the Adult Day Health Manual. The revised Subchapter 6 is effective for dates of service on or after September 1, 2007. Transportation Service Code T2003 is used to claim for transportation to a variety of medical services, including adult day health services. MassHealth has changed the billing requirements associated with the use of this code. All adult day health transportation services using Service Code T2003 must be billed as one-way trips (one unit of service). Round-trip billing on one claim line will no longer be accepted. A round trip must be billed as two one-way trips, one per claim line. For electronic 837P claim transactions, placing an “X” in the Ambulance Transport Code to indicate a round trip will no longer be accepted. If you have any questions about the information in this transmittal letter 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. NEW MATERIAL (The pages listed here contain new or revised language.) Adult Day Health Manual Pages 6-1 and 6-2. OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Adult Day Health Manual Pages 6-1 and 6-2 — transmitted by Transmittal Letter ADH-20 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Adult Day Health Manual Transmittal Letter ADH-22 Date 09/01/07 601 Service Codes and Descriptions: Per Diem Services MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 404.000 and 450.000. An adult day health provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Adult Day Health Manual. Service Code - Modifier Service Description S5102 Day care services, adult; per diem. (Use for adult day health-basic level of care.) S5102-U1 Day care services, adult; per diem. (Use for adult day health-HPPR.) S5102-TG Day care services, adult; per diem. (Use for adult day health-complex level of care.) 602 Service Codes and Descriptions: Transportation Services See 130 CMR 404.413. Service Code - Modifier Service Description T2003 Nonemergency transportation; encounter/trip. (Use for transportation furnished on a single date or on consecutive dates. All transportation services must be billed as one-way trips; round trips should be billed as two one-way trips.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Adult Day Health Manual Transmittal Letter ADH-22 Date 09/01/07 This page is reserved