Pharmacy Manual for MassHealth Providers

Read this section if you are looking for general MassHealth regulations about billing and administrative practices.

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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 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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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.

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