The Acute Inpatient Hospital Manual guides providers to the regulations and the administrative and billing instructions they need.
Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals.
Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For acute inpatient hospital providers, those matters are covered in 130 CMR 415.000, reproduced as Subchapter 4 in the Acute Inpatient Hospital Manual.
In-state acute inpatient hospitals should also refer to the RFA (Request for Application) signed by the hospital for the current rate year for additional requirements.
Read this section if you are looking for general MassHealth regulations about billing and administrative practices.
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Subchapter 4: Acute Inpatient Hospital Provider Regulations
Subchapter 4: Acute Inpatient Hospital Provider Regulations
This section explains to MassHealth providers how to determine eligibility, submit prior authorizations, and file claims.
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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.
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This appendix contains lists of third-party-liability (TPL) coverage-type codes and carrier codes to help you identify a member's other insurance.
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This appendix contains specific MassHealth billing instructions for claims for members who have Medicare or commercial insurance.
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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.
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This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions.
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This appendix includes the revenue codes that may be used by acute inpatient hospitals when billing for MassHealth-covered acute inpatient hospital services
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This appendix lists covered codes for children who are eligible for the Children’s Medical Security Plan (CMSP).
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This appendix lists events that are designated by the Massachusetts Department of Public Health (DPH) as Serious Reportable Events that are not considered Provider Preventable Conditions.
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This appendix describes the MassHealth billing instructions for Provider Preventable Conditions, as they apply to providers.
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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.
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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.
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This appendix lists the active Eligibility Verification System (EVS) codes and their respective service restriction messages.
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The following services are payable in addition to the initial, periodic, or interperiodic Early and Periodic Screening, Diagnosis and Treatment (EPSDT) or Preventive Pediatric Health-care Screening and Diagnosis (PPHSD) visit when they are performed and interpreted in the office of the provider who furnished the visit.
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