Guide MassHealth Provider Manual Appendices

MassHealth updates the generic appendices contained in all provider manuals (Appendices A, C, T, U, V, W, X, Y, and Z) as needed.

All Provider Manual Appendices A, C, T

Appendix A: Directory

This appendix contains the names, addresses, and telephone numbers of units, agencies, and contractors that you may need to contact in the course of doing business with MassHealth.

Appendix C: Third-Party-Liability Codes

This appendix contains lists of third-party-liability (TPL) coverage-type codes and carrier codes to help you identify a member's other insurance. The MassHealth Recipient Eligibility Verification System (REVS) reports TPL coverage-type and carrier codes for all applicable insurance coverage listed on file for each member.

Appendix T: CMSP Covered Codes

This appendix lists CMSP covered codes.

Additional Resources

All Provider Manual Appendices U, V, W

Appendix U: DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions

This appendix lists events that are designated by the Massachusetts Department of Public Health (DPH) as “Serious Reportable Events (SREs)” in accordance with 105 CMR 130.332 (or 105 CMR 140.308, as applicable) that are not considered “Provider Preventable Conditions” (PPCs) under MassHealth. These SREs are subject to applicable MassHealth provisions on “Serious Reportable Events” set forth, in the case of DPH-licensed hospital providers, in the hospital’s agreement with MassHealth governing payment for services, or in the case of freestanding ambulatory surgery centers, in Transmittal Letter FAS-25.

Appendix V: MassHealth Billing Instructions for Provider Preventable Conditions

This appendix describes the MassHealth billing instructions for Provider Preventable Conditions (PPCs), as they apply to providers. The appendix is subdivided into three parts: (1) billing instructions for PPCs for inpatient hospitals; (2) billing instructions for PPCs for outpatient hospitals and freestanding ambulatory surgery centers; and (3) billing instructions for PPCs for all other MassHealth providers.

Appendix W: EPSDT Services Medical and Dental Protocols and Periodicity Schedules

This appendix lists the services required under the Early and Periodic Screening, Diagnosis and Treatment (EPDST) Program, and the ages at which those services must be provided.

Additional Resources

All Provider Manual Appendices X, Y, Z

Appendix X: Family Assistance Copayments and Deductibles

MassHealth will pay for certain copayments, deductibles, and coinsurance amounts for certain MassHealth Family Assistance members under age 19. This appendix describes who is eligible, the types of copayments, deductibles, and coinsurance amounts that are covered, and how to bill for these services.

Appendix Y: EVS Codes and Messages

This appendix lists the active Eligibility Verification System (EVS) codes and their respective service restriction messages.

If you are looking for EVS system-generated message numbers, their corresponding unique message numbers, and their respective restrictive message text for MassHealth managed care health plans effective March 1, 2018, see the EVS Codes and Restrictive Messages for Managed Care Health Plans section on the Provider PCDI Resources page. 

Appendix Z: EPSDT/PPHSD Screening Services Codes

This appendix lists the services that are payable in addition to the EPSDT periodic visit when they are performed and interpreted in the office of the provider who furnished the visit.

Additional Resources

Provider-Specific Appendices

Updates to provider-specific manual appendices are automatically mailed to relevant providers.

Acute Inpatient Hospitals

Appendix D: Supplemental Instructions for Claims with Other Insurance

This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04. 

Appendix E: Information Required for the Utilization Management Program

This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission. It also provides contact information for the MassHealth Utilization Management Program contractor.

Appendix F: Admission Guidelines

This appendix contains a crosswalk of revenue codes and related HCPCS codes.

Additional Resources

Acute Outpatient Hospitals

Appendix D: Utilization Management Program

This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission. It also provides contact information for the MassHealth Utilization Management Program contractor.

Appendix E: Admission Guidelines

This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Appendix F: Revenue Codes

This appendix contains a crosswalk of revenue codes and related HCPCS codes.

Additional Resources

Adult Day Health Manual

Appendix D: Dementia Day Service

This appendix contains guidelines for adult day health programs that offer services to dementia populations.

Additional Resources

Chronic Disease and Rehabilitation Inpatient Hospital Manual

Appendix D: Supplemental Instructions for Claims with Other Insurance

This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

Additional Resources

Community Health Center Manual

Appendix D: Supplemental Instructions for TPL Exceptions

This appendix contains supplemental instructions for TPL exceptions.

Appendix E: Utilization Management Program

This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission. It also provides contact information for the MassHealth Utilization Management Program contractor.

Appendix F: Admission Guidelines

This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Additional Resources

Dental Manual Appendices E, F, G

Appendix E: Intraoral Complete Series of Radiographic Images

This appendix contains information on intraoral complete series of radiographic images

Appendix F: Authorization for Interceptive Orthodontic Treatment

This appendix contains information about authorization for interceptive orthodontic treatment.

Appendix G: Utilization Management Program

This appendix lists information admitting providers or designees must give the MassHealth Utilization Management contractor when proposing an elective admission. It also provides contact information for the MassHealth Utilization Management Program contractor.

Additional Resources

Dental Manual Appendix H

Appendix H: Admission Guidelines

This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Additional Resources

Freestanding Ambulatory Surgery Center Manual

Appendix E: Admission Guidelines

This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Additional Resources

Home Health Agency Manual Appendix D

Appendix D: Supplemental Instructions for TPL Exceptions

This appendix contains billing instructions for submitting 837I and 837P transactions, paper claims, and direct data entry (DDE) claims for members who have Medicare or commercial insurance, and whose services are determined not covered by the primary insurer. This appendix lists the exceptions that need to be considered when billing MassHealth, for members who have Medicare or commercial insurance. These are specific MassHealth billing instructions that are not described in the HIPAA implementation guides for the 837I and 837P transactions, in the 837I and 837P companion guides, or in the billing guides for the UB-04 or CMS-1500 claim forms.

Additional Resources

Home Health Agency Manual Appendix E

Appendix E: Criteria for Provider Liability

This appendix explains the review criteria that MassHealth uses to determine home health agency liability for invalid home health advanced beneficiary (HHABN) notices.

Additional Resources

Mental Health Center

Appendix D: Supplemental Instructions for TPL Exceptions

This appendix contains supplemental instructions for TPL exceptions.

Additional Resources

Nursing Facility Manual Appendices D, E, F

Appendix D: Specification for Electronic Submission of MMQ

This appendix provides specifications for submitting Management Minutes Questionnaire (MMQ) information electronically.

Appendix E: Instructions for Completing MMQ

This appendix provides instructions for completing initial and semiannual Management Minutes Questionnaires (MMQ).

Appendix F: Unit-Dose Drugs

This appendix lists the unit-dose packaged drugs that a nursing facility must return to the dispensing pharmacy in accordance with 130 CMR 456.621, when the use of the drug for the member is discontinued.

Additional Resources

Nursing Facility Manual Appendix G

Appendix G: Supplemental Instructions for TPL Exceptions

This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

Additional Resources

Pharmacy Manual

Appendix D: Unit-Dose Drugs 

This appendix lists the unit-dose-packaged drugs that the dispensing pharmacy must credit to MassHealth when they have been dispensed to a MassHealth member in a nursing facility and have been returned by the nursing facility in accordance with 130 CMR 406.446.

Additional Resources

Physician Manual

Appendix E: Admission Guidelines

This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Appendix I: Utilization Management Program

This appendix is a list of information the admitting provider or designee must give the MassHealth Utilization Management contractor when proposing an elective admission. MassHealth may request additional information at any time to clarify the details of any admission. See 130 CMR 450.208 for regulations about admission screening.

Appendix K: Teaching Physicians

This appendix contains service codes for which a teaching physician may bill MassHealth even though he or she is not physically present for the key portions of the service. Note: This exception does not apply in certain circumstances if the teaching physician is also a primary care clinician in the Primary Care Clinician Plan. (See 130 CMR 450.275.)

Additional Resources

Podiatrist Manual Appendix E

Appendix E: Utilization Management Program

This appendix is a list of information the admitting provider or designee must give the MassHealth Utilization Management contractor when proposing an elective admission. MassHealth may request additional information at any time to clarify the details of any admission. See 130 CMR 450.208 for regulations about admission screening.

Additional Resources

Podiatrist Manual Appendix F

Appendix F: Admission Guidelines

This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.

Additional Resources

Psychiatric Inpatient Hospital

Appendix D: Supplemental Instructions for TPL Exceptions 

This appendix contains billing instructions for submitting 837I transactions and paper claims for members who have Medicare and/or commercial insurance, and whose services were deemed by the payer to be noncovered because the patient does not have benefits available (benefits exhausted), or does not qualify for a new benefit period. It contains specific MassHealth billing instructions that are not described in the HIPAA Implementation Guide for the 837I transaction, in the 837I Companion Guide, or in the billing guides for the UB-04.

Additional Resources

Sterilization Clinic Manual

Appendix E: Utilization Management Program

This appendix is a list of information the admitting provider or designee must give the MassHealth Utilization Management contractor when proposing an elective admission. MassHealth may request additional information at any time to clarify the details of any admission. See 130 CMR 450.208 for regulations about admission screening.

Additional Resources

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