Administrative Advisory SPED 2019-3

Administrative Advisory SPED 2019-3

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

To:Administrators of Special Education, Executive Directors of Collaboratives and Executive, Program Directors of Approved Special Education Schools, Medicaid Contractors and other Interested Parties
From:Russell Johnston, Senior Associate Commissioner
Rachelle Engler Bennett, Associate Commissioner
Date:May 10, 2019

As part of recent updates to the Medicaid claiming process, the Department of Elementary and Secondary Education (Department) has updated Form 28M/12. This form is used to provide service delivery information that meets the service delivery documentation requirements for billing under the School-Based Medicaid Program.

Out-of-district programs operated by approved special education schools and educational collaboratives must complete Parts I and II of Form 28M/12 and send it to the responsible public school district (Local Education Agency) in a timely manner consistent with the Medicaid billing reimbursement timelines. The public school district must complete Part III prior to submission for reimbursement.

The Department has updated the form to reflect recent changes in the School-Based Medicaid Program effective July 1, 2019. This form is “mandated,” and is reserved for use by out-of-district programs. Form 28M/12 contains all required information and data that should be provided by the out-of-district program and the public school district. Out-of-district programs and public school districts may only use a different format for submitting information for reimbursement if it is mutually agreed upon and if it contains all required elements. An out-of-district program may also use this form to document service delivery, though it is not required for that purpose.

Only qualified Service Providers need to document Medicaid Eligible services provided to a student. To learn what qualifications are required, please review the Local Education Agencies Covered Services and Qualified Practitioners document.

For information about requirements for interim claiming in the School-Based Medicaid Program, all qualified practitioners should review the SBMP Direct Service Interim Claiming Guide. This guide reviews the guidelines for Medicaid reimbursement of qualified medical services, including the requirements for service authorization, service documentation, and medical necessity. Should you have additional questions, please contact the Office of Student and Family Support at 781-338-3010 or

I hope this information is helpful. We continue to work on additional technical assistance to help school districts, approved special education schools, and educational collaboratives to work together in our participation in the School-Based Medicaid program.


Download Word Document
Massachusetts School Based Medicaid Service Documentation for Day/Residential Special Education Schools (28M/12) — updated May 2019

Last Updated: May 10, 2019