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Hha 46 (Commonwealth of Massachusetts)

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Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA 02111
www.mass.gov/masshealth
MassHealth
Home Health Agency Bulletin 46
January 2009
TO: Home Health Agencies Participating in MassHealth
FROM: Tom Dehner, Medicaid Director
RE: New Home Health Coverage Determination Form
Background MassHealth is implementing a new Home Health Coverage Determination
Form. This form is accessible and is fillable online on the MassHealth
Web site. This form must accompany all commercial coverage
determinations, or Explanations of Benefits (EOBs), submitted to
MassHealth. For more information, please refer to Transmittal Letter
HHA-33 (June 2002) and Home Health Agency Bulletin 41 (November
2003). Please note that this bulletin transmits modifications to the
qualifying event definitions. For members that have both commercial
insurance and MassHealth, providers must submit a coverage
determination from the primary insurer any time the member’s medical
condition, resulting in a change of skilled services in the plan of care, or
health-insurance-coverage status changes.
Submitting Claims MassHealth does not accept annual EOBs for services denied by
to MassHealth the commercial insurer. MassHealth is always the payer of last resort.
Home health providers must bill, obtain, and send an EOB from the
primary insurer whenever the member has a qualifying event. Providers
must submit a copy of the EOB to MassHealth within 10 days of receiving
notification of denial from the insurer. Providers must continue to submit
paper
coverage determinations for all qualifying events, whether billing
electronically or on paper.
Third-Party Liability Billing requirements are contained in MassHealth’s third-party liability
Requirements (TPL) regulations at 130 CMR 450.316 and 450.317.
Qualifying Event A qualifying event is defined as any change in a member’s condition or
circumstances, including a change in health insurance plans that may
trigger a change in insurance coverage. The following list includes some
examples of qualifying events that require a provider to request coverage
and obtain an Explanation of Benefits (EOB) from a commercial insurer.
(continued on next page)
MassHealth
Home Health Agency Bulletin 46
January 2009
Page 2
Qualifying Event Qualifying/triggering events include, but are not limited to the following:
(cont.)
• a new admission to a home health agency (HHA);
• a readmission to HHA after a discharge from an inpatient hospital or
skilled facility stay; resulting in a change of skilled services in the plan
of care;
• cessation of commercial insurance coverage or
change of insurance
(Complete and submit a TPLI form with the EOB and new Home
Health Coverage Determination Form.);
• exhaustion of annual commercial insurance coverage or
other periodic
benefit(s);
• reinstatement of insurance benefits;
• change in the patient’s medical condition resulting in a change of
skilled services in the plan of care.
Submitting Home
Submit a completed Home Health Coverage Form with every coverage
Health Coverage determination. It can
be faxed to 617-886-8133 or mailed to the following
Determination Forms address.
MassHealth
Home Health Claims
The Schrafft’s Center
529 Main Street, 3
rd
Floor
Charlestown, MA 02129
MassHealth’s Right
MassHealth reserves the right to appeal any insurer’s denial of coverage
to Appeal and Audit
if it determines that the service may be covered under the member’s
insurance policy. Providers must, at MassHealth’s request, submit the
claim and related clinical or service documentation to MassHealth or to an
insurance carrier, or both, if MassHealth determines that the provider’s
submission is needed for MassHealth to exercise this right of appeal.
MassHealth also reserves the right to perform audits to ensure
compliance with all TPL regulations. Providers must, at MassHealth’s
request, submit the requested documentation to MassHealth in order to
substantiate the service(s) provided to the member, in accordance with
130 CMR 450.205.
(continued on next page)
MassHealth
Home Health Agency Bulletin 46
January 2009
Page 3
Requesting a A copy of the Home Health Coverage Determination Form is attached. It
Supply is accessible on the MassHealth Web site at www.mass.gov/masshealth
by clicking on the link for MassHealth Provider Forms in the lower right
corner of the page.
Requests for paper copies of this form must be submitted in writing and
faxed to 617-988-8973 or mailed to the following address.
MassHealth
ATTN: Forms Distribution
P.O. Box 9118
Hingham, MA 02043
Questions If you have any questions about the information in this bulletin, 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.
.
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
www.mass.gov/masshealth
Home Health Coverage Determination Form
(Attach EOB from primary insurer to this form.)
HHCD-1 (01/09)
Date:
Member Name: Member ID:
Diagnosis:
Dates of Service: to
Services Provided (Check all that apply.):
Skilled Nursing Continuous Skilled Nursing Physical Therapy
Occupational Therapy Speech/Language Pathology Home Health Aide
Qualifying/Triggering Event (Check one.):
New admission to a home health agency (HHA)
A readmission to an HHA after a discharge from an inpatient hospital or skilled facility stay;
resulting in a change of skilled services in the plan of care
Cessation of commercial insurance coverage or a change of insurance
(attach a completed TPLI form)
Exhaustion of annual commercial insurance coverage or other periodic benefit(s)
Reinstatement of insurance benefits
Change in the patient’s medical condition resulting in a change of skilled services
in the plan of care
Please provide a brief description of change:
Is this a personal injury protection (PIP) case? yes no
Are you covending? yes no
If yes, name of covendor:
Provider Name:
Provider Address:
Branch Address:
Contact Name:
Contact Phone/Fax No.:
MassHealth Provider No.:
NPI:
Send to: MassHealth
Home Health Claims
The Schraffts Center
529 Main Street, 3rd Floor
Charlestown, MA 02129
Fax: 617-886-8133
Purpose of Home Health Coverage Determination (HHCD) Form
The MassHealth HHCD Form is used by home health agencies to show compliance with MassHealth’s third-party
liability (TPL) regulations (130 CMR 450.316 and 450.317). For members with commercial insurance in addition to
MassHealth, providers must submit claims to the commercial insurer for a coverage determination before submitting
the claim to MassHealth. Coverage determinations and explanations of benefits (EOBs) must be obtained whenever
a member has a qualifying event. The HHCD Form must accompany the coverage determination and/or EOB to
MassHealth within 10 days of the provider’s receipt of the EOB. Home health providers must continue to submit
paper coverage determinations for all qualifying events whether billing electronically or on paper.
Instructions for Completing the HHCD Form
Provider Information:
Fill in your provider name, branch address, and contact’s phone and fax numbers.
MassHealth Provider No.:
Fill in your MassHealth provider number.
NPI:
Fill in your national provider identifier (NPI) number.
Date:
Fill in the date you are sending the form and accompanying EOB to MassHealth.
Member Name:
Fill in the member’s name.
Member ID:
Fill in the member’s ID number.
Diagnosis:
Fill in the diagnosis/diagnoses; ICD-9 codes are not necessary.
Dates of Service:
Fill in the dates you want MassHealth to start and end payment. If there is no end date,
enter a start date and indicate “ongoing.”
Services Provided:
Check off all services the agency is providing to the member.
Qualifying/Triggering Event:
Check off the reason the provider obtained the initial EOB or new EOB. If you are notifying us of a change in
insurance, please complete both the HHCD Form and the TPLI form and send both with the EOB. Both forms are
accessible from the MassHealth Web site at www.mass.gov/masshealth by clicking on the link for MassHealth
Provider Forms in the lower right corner of the page.
Description of Change:
Indicate why the primary insurance company was billed.
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Completed 26 July 2020

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