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Guide Physician (PHY) Manual

The Physician Manual contains the regulations, administrative and billing instructions, and service codes for physicians, nurse midwives, independent nurse practitioners, portable X-ray providers, and diagnostic imaging centers. The Executive Office of Health and Human Services (EOHHS) establishes rates for MassHealth services. See 101 CMR 316.00, 101 CMR 318.00, and 101 CMR 317.00.

MassHealth issues transmittal letters to update any part of the provider manual. MassHealth issues provider bulletins to communicate information that is not contained in the provider manual.

Each part of the Physician Manual is listed below from beginning to end. You can print each part separately (or any individual pages) or print all parts for a complete manual.

Table of Contents

Table of Contents

  • Table of contents pages i, ii, ii-a, and iii appear at the beginning of Subchapter 1 below
  • Table of contents page iv appears at the beginning of Subchapter 4 below
  • Table of contents page v (see below)
  • Table of contents page vi (see below)

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Preface

See below for the Physician (PHY) Manual Preface.

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Subchapters 1 through 3

Administrative and Billing Regulations (apply to all providers).

Additional Resources for Subchapters 1 through 3

Subchapter 4

See below for the Physician (PHY) regulations.

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Subchapter 5

The Administrative and Billing Instructions (Subchapter 5) are divided into seven parts. For instructions for electronic billing, refer to the MassHealth Companion Guides. To request a copy of any of the MassHealth Companion Guides please contact MassHealth Customer Service Center at 1-800-841-2900. For instructions for billing MassHealth using paper claim forms refer to MassHealth Billing Guides for Paper Claim Submitters.

Please see below for Subchapter 5: Administrative and Billing Instructions.

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Subchapter 6

See below for service codes for the Physician (PHY) Manual.

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MassHealth All Provider Manual Appendices

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

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Physician Manual Appendices

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.)

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