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Special Education

New State Mandated Form for Documentation of Medicaid Service Delivery in Out-of-District Settings (28M/12)

To:Special Education Administrators, Private School Directors, Educational Collaborative Directors, Medicaid Contractors and other Interested Parties
From:Marcia Mittnacht, State Director of Special Education
Date:October 26, 2010

In a partnership effort between the Department of Elementary and Secondary Education, the Office of Medicaid, the Massachusetts Association of Approved Private Schools, and the Massachusetts Association of Administrators of Special Education we have agreed upon a format for providing service delivery information that conforms to the required service delivery documentation required for billing under the School-Based Medicaid Program. Out-of-district settings serve students from multiple public school districts and the task of providing service delivery information in multiple formats to meet various school district needs has demanded too many resources from out-of-district programs. *

The attached form is now a "mandated" form (28M/12), reserved for use by out-of-district programs operated by approved private schools or educational collaboratives. By developing this as a mandated form, any out-of-district program may use this form to document service delivery. If this form is used, all public school districts must accept this documentation in this form and may not insist on another format of their choice. This form and format is the only format that an out-of-district program may insist upon. Public school programs are not required to use this form for in-district service delivery documentation. While out-of-district programs are not required to use this form, it is highly recommended and clearly outlines required data that is provided by the out-of-district staff (Parts I & II) and data that the public school district provides (Part III).

Two forums were held in October to introduce the form and gather questions regarding the documentation of service delivery. A couple of items were raised that deserve mention here:

  • The original 28M/12 (distributed at our initial forum on Wednesday, October 6) did not contain a column for "Procedure Codes" --- as you will see, this final form does contain such a column. This is information that must be provided by the service provider in Part 1 of the form. Service Providers may find reviewing School-Based Medicaid Bulletin #18 (at: helpful in identifying the proper service code.
  • Only qualified Service Providers will need to document Medicaid Eligible services provided. If you have questions about what qualifications are needed to be "qualified," you may find reviewing the School-Based Medicaid Bulletin #17 (at: helpful. In addition to other information, Bulletin #17 includes practitioner qualifications.

I hope this information is helpful. Our partnership members continue to work on additional technical assistance to help school districts and private approved schools to work together in our participation in the School-Based Medicaid program.


Download PDF Document  Download MS WORD Document Massachusetts School Based Medicaid Service Documentation for Day/Residential Special Education Schools (28M/12) (revised February 2012)


Last Updated: October 28, 2010

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