Important. Please Read NewMMIS Notices - by Function

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On November 27, 2009, MassHealth will discontinue use of the former EDI  Web Portal that supported legacy MMIS for electronic transactions (files created before implementation of NewMMIS in May 2009). If you need copies of any 835 or 997 transactions that were created before June 2009, you must download the files before November 27, 2009, at www.mass.gov/masshealth.gov. Click on Information for MassHealth Providers, then on MassHealth Claims Submission, then on Web-Based MassHealth Transactions, and then on Production Transactions.

After November 27th, only 835 and 997 files created since NewMMIS implementation will be accessible on the Provider Online Service Center (POSC) at www.mass.gov/masshealth/providerservicecenter.

MassHealth Customer Service has contacted any users of the former EDI Web portal that have accessed the site within the last three months to inform them of this change. 

For additional information about this transition, please refer to All Provider Bulletin 185 and All Provider Bulletin 187.

NewMMIS and Provider Online Service Center (POSC) System Maintenance Sunday 11/22 from 7:00 am to 11:00 am and 6:00 pm to 11:00 pm

The NewMMIS POSC, including the internal NewMMIS application, all eligibility services, the Voice Response application and EVSpc will be unavailable Sunday 11/22 from 7:00 am to 11:00 am and 6:00 pm to 11:00 pm due to system maintenance. Thank you for your patience during these scheduled maintenance windows and for your continued service to the Mass Health program.                                             

** For more information about these notices or any previous notices, please visit www.mass.gov/masshealth/newmmisnotices

Masshealth Issues Member Seasonal Flu and H1N1 (Swine) Flu Informational Flyer

MassHealth has prepared an informational flyer to inform MassHealth members about coverage of the seasonal flu and H1N1 (swine) flu vaccines.  This informational flyer can be used as a resource to help providers inform their members about their MassHealth seasonal and H1N1 flu vaccine coverage. The flyer addresses vaccine eligibility concerns for both seasonal and H1N1 flu with regard to the member’s MassHealth plan requirements. The flyer also communicates some coverage limitations and lists further references for obtaining more flu-related information.

The flyer is being mailed to all households that have MassHealth members. You can download a PDF of the flyer by clicking on the Seasonal and H1N1 Flu Vaccine Coverage for MassHealth Members link under the News & Updates column on the home page of the MassHealth Web site.

For more information about the administration of the H1N1 vaccine, please refer to All Provider Bulletin 197, dated October 2009, available from the Provider Library at www.mass.gov/masshealthpubs.

To all MassHealth Providers

In anticipation of the upcoming holiday season, we wish to inform you that steps have been taken so that payments will not be delayed nor otherwise affected due to the holidays. The normal schedule will apply for posting the provider Remittance Advices and 835 transactions on the NewMMIS Provider Online Service Center.

NewMMIS and Provider Online Service Center (POSC) System Maintenance Sunday 11/1 from 6:00 pm to 10:00 pm

The NewMMIS POSC, including the internal NewMMIS application, all eligibility services, the Voice Response application and EVSpc will be unavailable Sunday 11/1 from 6:00 pm to 10:00 pm due to system maintenance. Thank you for your patience during these scheduled maintenance windows and for your continued service to the Mass Health program.

Passwords must contain:

• Between 8 and 16 characters
• One upper case character (i.e., A, B, C)
• One lower case character (i.e., a, b, c,)
• One number (i.e., 1, 2,3)

Passwords cannot contain:

• The words "test", "password" or "pass"
• Your first name, your last name, or your full name
• Your account ID
• Your email address
• Any recently used password

** For more information about this notice or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices.

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EVS Health Safety Net (HSN) Secondary Messaging Issue Has Been Resolved

Previously, EVS incorrectly displayed the following restrictive message when a patient was eligible for Health Safety Net or Partial Health Safety Net and there was no other health insurance on file on the date of service searched: 

"Member is HSN Secondary. Bill member’s private health insurance. See 114.6 CMR 13.00 for info on TPL REQs." 

This restrictive message now only appears when the member has other insurance that is known to MassHealth.  This issue has now been resolved.  If you have any questions, please contact the Health Safety Net Helpdesk at 1-877-910-2100.

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** For more information about this notice or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices

In an effort to help ease transition to NewMMIS, MassHealth relaxed the enforcement of the standard security requirement to change passwords every 90 days on the Provider Online Service Center (POSC). Now that it has been almost four months since NewMMIS implementation, MassHealth will reinstate enforcement of this policy beginning this Wednesday, September 23, 2009. 

After September 23, providers with passwords that have been in effect for more than 90 days will be prompted to change passwords. In addition, if your password is due to expire within 15 days of the standard 90-day period, you will receive a password expiration prompt and the option to make the change when you log in.  Please be sure to follow the instructions on the screens if you receive these prompts.  Thank you for your patience and cooperation. 

Passwords must contain:

• Between 8 and 16 characters
• One upper case character (i.e., A, B, C)
• One lower case character (i.e., a, b, c,)
• One number (i.e., 1, 2,3)

Passwords cannot contain:

• The words "test", "password" or "pass"
• Your first name, your last name, or your full name
• Your account ID
• Your email address
• Any recently used password

** For more information about this notice or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices.

PIN Registration for New MMIS Provider Online Service Center (POSC) has been extended to September 30, 2009

MassHealth has heard your request for additional time to register to access the Provider Online Service Center (POSC), and has extended the registration period. The last day a provider may register on the POSC using their PIN will be September 30, 2009. After this date, the Primary User for each provider organization will be required to contact MassHealth Customer Service to gain access to the POSC. If you have not yet registered, we strongly urge you to take full advantage of the additional time to complete the POSC registration before September 30, 2009.  Thank you for your cooperation.

** For more information about these notices or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices 

Atypical Providers Billing with the NewMMIS Provider ID Service Location (PID SL)

MassHealth identified a system issue for atypical providers submitting 837I and 837P transactions using their PID SL. The system is dropping the service location (SL) from the PID SL, causing claims to deny for EOB code 254-Billing Provider Location Missing. This issue is being corrected by Thursday, July 16, 2009. Please note that paper claims and direct data entry (DDE) claims have not been affected. The claims that were denied erroneously as a result of this issue will be reprocessed at a future date. Providers can wait for the reprocess of these claims or resubmit them through EDI after July 16 or through direct data entry (DDE) or on paper. If you have questions please call MassHealth Customer Service at 1-800-841-2900. 

Important Update:

New MMIS POSC Primary Users Modifying Permissions for Subordinate Users

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When billing for H1N1 vaccine administration for dates of service before 10/18/09, when the sole purpose for the visit is vaccine administration, providers should use unlisted CPT Code 90749 and attach an office note indicating H1N1 administration. This code will be priced and paid as indicated in All Provider Bulletin 197.

Effective for dates of service on and after 10/18/09, follow the instructions in All Provider Bulletin 197, dated October 2009. To download a copy of the bulletin from the Provider Library, go to www.mass.gov/masshealthpubs.

Whenever possible, providers should make every effort to administer flu vaccines during regular visits with their members. In such cases, MassHealth will not provide any additional payment for administering the vaccine (s). In instances where providers cannot administer the H1N1 vaccine as part of a regular visit, MassHealth will pay only for the administration of the H1N1 vaccine, and will pay all providers the same fee, regardless of the provider type, in accordance with DHCFP Medicine regulation 114.3 CMR 17.00.

Pre-Admission Screening (PAS) Function Unavailable from Friday, 10/30 at 9:00 pm to Sunday, 11/1 at 10:00 pm

October 30^th is the last day that MassPro will process Pre-Admission Screening (PAS) Acute Hospital and Acute with Rehab Hospital requests. Permedion will take over this function starting Monday, November 2^nd.  In preparation for this change-over, providers will not be able to submit requests via the PAS panel on the Provider Online Service Center (POSC) from Friday, 10/30 at 9:00 pm to Sunday, 11/1 at 10:00 pm. 

To Home Health Agencies and Independent Nurses:  Prior Authorization Numbers Required on Claims for Procedure Codes T1002 and T1003

MassHealth previously announced the reprocessing of claims for continuous nursing services, single rate night shift and single rate weekends (T1002 UJ and T1003 UJ), that denied erroneously. All affected claims were due to be reprocessed and appear on remittance advice 100020, dated October 13, 2009. However, MassHealth has since discovered that only those claims having a prior authorization (PA) number were reprocessed at that time.

If your T1002 UJ and T1003 UJ claim was not processed on RA 100020, please resubmit it as if it were a new claim. Be sure to include the PA number but do not include the former internal control number (ICN) number.

Going forward, you must include a PA number on all continuous skilled nursing services (T1002 and T1003) claims submissions or your claims will be denied.  Thank you for your patience and cooperation.

** For more information about these notices or any previous notices, please visit www.mass.gov/masshealth/newmmisnotices

1-877-735-7416 (Permedion Phone)
1-877-735-7415 (Permedion Fax)

Permedion HMS Government Services
510 Rutherford Ave.
Charlestown, MA 02129 

Prior Authorizations with Status of "In Process" to be Deleted on September 30, 2009

Please be advised that on September 30, all Prior Authorization (PA) requests created between May 16, 2009 and August 31, 2009 with a status of IN PROCESS will be deleted. PA requests with a status of IN PROCESS represent PAs that were started but never submitted to MassHealth.

** For more information about this notice or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices.

Please be advised that on September 30, all Prior Authorization (PA) requests created between May 16, 2009 and August 31, 2009 with a status of IN PROCESS will be deleted. PA requests with a status of IN PROCESS represent PAs that were started but never submitted to MassHealth.

** For more information about this notice or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices.

MassHealth has identified some issues in the Prior Approval (PA) area that are expected to be corrected over the next few weeks. These changes will enable the MassHealth PA Unit to process requests more quickly and eliminate any backlog. Please be assured that MassHealth is committed to resolving these issues expeditiously, and to working with providers to ensure that services to members are not interrupted, and that members newly requesting services receive timely access to those services. To that end, we've determined that additional training would help providers during this time to work through the issues and to enhance their overall understanding of the new system and processes. The next training addressing PA/PAS issues is scheduled for August 15. You may register for a session through the MassHealth e-Learning system at http://masshealthnewmmisprovidertraining.
ehs.state.ma.us/default.asp.

Once logged in, open the Course Catalog and select NewMMIS Question and Answer Sessions by Topic for Providers. Click on View Course Details and Enroll. To register for a session, click on Session Schedule tab and select the applicable Action button.

While we address these issues, here is some information that will be helpful to you:

Please be aware that Personal Care Attendant (PCA) PAs are being extended to eliminate a break in service. When the new PA is adjudicated the extension will be end-dated and the new PA will start the next day. To further assist PCA providers, MassHealth is updating the job aids regarding prior authorization to make those job aids specific to the PCA program.

Durable Medical Equipment (DME) providers should e-mail Tania.Gray@state.ma.us and "cc:" cemilia.ceme@state.ma.us if they have specific PAs that are about to expire in order for the PAs to be adjudicated immediately. To help MassHealth concentrate on PAs whose expiration date is imminent, DME providers are asked not to contact MassHealth about PAs that are not due to expire until August.

All providers: Be sure to check EVS before submitting PA's to determine if the member is eligible. Please note a warning message will also display if you attempt to submit a PA via the POSC for a member that is not eligible.

Voiding PAs: If you previously encountered difficulty voiding PAs, please be advised that this issue has been resolved and you should now be able to void a PA if you have changed your mind and no longer want to submit the PA to MassHealth. Once the PA has been submitted to MassHealth you will need to contact the PA Unit if you want to void the PA.

Searching using an old provider number: You can search for PAs using your old provider number but please be advised that two zeros must be inserted in front of your "legacy" provider number.

Duplicate Errors: In certain circumstances providers get a "duplication" error when they attempt to submit a PA. To avoid this error, change the service date by one day (so it does not duplicate against the previous PA). This allows the PA to go through. You should indicate the correct service dates in the comment section and MassHealth will update the dates on the PA.

E-fax issue: MassHealth is experiencing problems viewing some of the attachments that come in via e-fax. Please note that the PA Unit will contact you if there is a problem viewing your attachments. Work is underway to resolve this issue. We will keep you posted as to resolution progress. Please do not stop using e-fax service as, absent the ability to upload scanned documents, this is the most expeditious way to submit your attachments with your electronic PA submission.

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Adult Day Health Services (ADH) Claims Reprocess

MassHealth initiated scheduled maintenance to ADH service codes on October 2, 2009.  The scheduled maintenance inadvertently caused some ADH service claims with dates of service between April 1, 2009 and October 23, 2009 to deny erroneously with Edit code 8121 (Adult Day Health Limit—1 Per Day). In addition, some claims were underpaid as a result of the maintenance.

MassHealth corrected the issue to ADH service codes on October 23, 2009 to ensure that future claims would process according to current billing procedures. MassHealth has systematically reprocessed all erroneously denied claims and adjusted claims that were underpaid. These adjustments will appear on the December 1, 2009 pay cycle.  Thank you for your patience.

** For more information about these notices or any previous notices, please visit www.mass.gov/masshealth/newmmisnotices.

MassHealth will be hosting a WebEx educational session to review how to enter TPL and Medicare crossover claims via DDE for Nursing Facility Providers. The sessions will allow providers to follow along as we enter a claim. We will then request providers to enter DDE claims themselves into production and ask questions as they go through the process. To register, please go to http://masshealthnewmmisprovidertraining.ehs.state.ma.us/

CORRECTION TO MESSAGE ISSUED LAST WEDNESDAY, NOVEMBER 4

All Provider Bulletin 194: Primary Care Clinician (PCC) Referral Process (June 2009) indicated that, effective November 30, 2009, MassHealth would no longer accept the use of legacy-based provider numbers for referrals from PCCs. MassHealth is extending this deadline, and will continue to accept legacy PCC referral numbers for all new and pre-NewMMIS referrals until further notice.

When entering the legacy referral number into the Referral field, you must include two leading zeroes before the legacy PCC provider number.

If you have claims that denied for Edits 3120 (Referral Required on Claim) or 3124 (Rendering Provider Does Not Match Referral Auth) you may resubmit those claims using the legacy PCC referral number in the referral field.

Please continue to check POSC Broadcast Messages for updates to instructions for submitting claims that require referrals. Thank you.                                                   

** For more information about these notices or any previous notices, please visit www.mass.gov/masshealth/newmmisnotices 

When billing for H1N1 vaccine administration for dates of service before 10/18/09, when the sole purpose for the visit is vaccine administration, providers should use unlisted CPT Code 90749 and attach an office note indicating H1N1 administration. This code will be priced and paid as indicated in All Provider Bulletin 197.

Effective for dates of service on and after 10/18/09, follow the instructions in All Provider Bulletin 197, dated October 2009. To download a copy of the bulletin from the Provider Library, go to www.mass.gov/masshealthpubs.

Whenever possible, providers should make every effort to administer flu vaccines during regular visits with their members. In such cases, MassHealth will not provide any additional payment for administering the vaccine (s). In instances where providers cannot administer the H1N1 vaccine as part of a regular visit, MassHealth will pay only for the administration of the H1N1 vaccine, and will pay all providers the same fee, regardless of the provider type, in accordance with DHCFP Medicine regulation 114.3 CMR 17.00.

To Home Health Agencies and Independent Nurses:  Prior Authorization Numbers Required on Claims for Procedure Codes T1002 and T1003 

MassHealth previously announced the reprocessing of claims for continuous nursing services, single rate night shift and single rate weekends (T1002 UJ and T1003 UJ), that denied erroneously. All affected claims were due to be reprocessed and appear on remittance advice 100020, dated October 13, 2009. However, MassHealth has since discovered that only those claims having a prior authorization (PA) number were reprocessed at that time.

If your T1002 UJ and T1003 UJ claim was not processed on RA 100020, please resubmit it as if it were a new claim. Be sure to include the PA number but do not include the former internal control number (ICN) number.

Going forward, you must include a PA number on all continuous skilled nursing services (T1002 and T1003) claims submissions or your claims will be denied.  Thank you for your patience and cooperation.

** For more information about these notices or any previous notices, please visit www.mass.gov/masshealth/newmmisnotices

WebEx Training Sessions to be Held for Provider DDE:  TPL/CST

MassHealth will host several WebEx educational sessions to review how to enter TPL and Medicare crossover claims via DDE. The sessions will allow providers to follow along as we enter the claims. We will then request providers to enter DDE claims for themselves into production and ask questions as they go through the process.  To register, please go to http://masshealthnewmmisprovidertraining.ehs.state.ma.us/

Session 1 - Institutional Claims with Medicare A/B Paid

Date: Wednesday, October 14, 2009

Time: 1:00 - 2:30 pm - Institutional Inpatient

Time: 3:00 - 4:30 pm - Institutional Outpatient or Outpatient Ancillary

Session 2 - Professional Claims with Medicare B Paid

Date: Wednesday, October 21, 2009

Time: 1:00 -2:30 pm

** For more information about these notices or any previous notices, please visit www.mass.gov/masshealth/newmmisnotices 

** For more information about these notices or any previous notices, please visit www.mass.gov/masshealth/newmmisnotices

1-877-735-7416 (Permedion Phone)
1-877-735-7415 (Permedion Fax)

Permedion HMS Government Services
510 Rutherford Ave.
Charlestown, MA 02129

MassHealth previously informed providers that NewMMIS supports the repricing of Medicare Part B Crossovers. MassHealth will pay Medicare Part B Crossover claims up to the MassHealth allowable amount less any Medicare payment, or the coinsurance and deductible amount, whichever is less. In calculating the difference between the MassHealth allowable amount and the Medicare payment, NewMMIS will apply the following payment rules:

1) If MassHealth has not adopted the Medicare code and has a comparable code for the service, it will use the comparable code and rate for payment. Please see "Medicare Code to MassHealth Comparable Code Cross Reference" listing.

2) If MassHealth has not adopted the code because it is a non-covered service, MassHealth will not pay the Medicare coinsurance and deductible. Please see attached documents "MassHealth Non-Covered Codes for All Pts" as well as "MassHealth Non-Covered Codes for Spec Prov Types" listings.
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If you have any questions, please contact MassHealth Customer Service at 1-800-841-2900. Thank you for your patience and cooperation.

Please be sure to review the Clinical Laboratory Services Rate regulation (114.3 CMR 20.04) to obtain the list of Service Codes subject to the ATP panel rate payment methodology. This regulation is available online by clicking on the Clinical Laboratory Services Rate regulations.

** For more information about this notice or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices

Update: Medicare Part B Crossover Claim Re-pricing

Utilization Management Program Updates For Acute Hospitals

MassHealth has made some changes to the Utilization Management Program for acute hospitals that will take effect on November 2, 2009. As a result of these updates, the annual volume of claims subject to pre-payment reviews will increase from 15,000 claims to 20,000, inpatient post-payment reviews will increase from 10,000 claims to 15,000 claims, and outpatient post-payment reviews will increase from 5,000 claims to 20,000 claims. Post-payment reviews will be conducted as a combination of mail-in and on-site reviews. Thank you for your continued cooperation.

Update: MassHealth HIPAA Trading Partner Testing Has Resumed

MassHealth resumed HIPAA compliance and comprehensive testing on September 9, 2009. Please call MassHealth Customer Service at 1-800-841-2900 to arrange trading partner testing before submitting any test files. Select Option 1, Option 8, then Option 3 to speak with an Electronic Data Interchange (EDI) unit representative to coordinate testing. You may also email your request to test electronic X12 transactions to hipaasupport@mahealth.net. Any test files submitted without prior knowledge and coordination with the EDI unit will not be monitored for review of results.

If you plan to use an approved billing intermediary or software vendor to submit electronically you do not have to test with MassHealth directly. EDI will still need to obtain certain necessary information however prior to testing with your billing intermediary or software vendor. For more information, please refer to testing instructions at www.mass.gov/masshealth/newmmis.

MassHealth has identified that 837P electronic claims submitted with National Drug Code (NDC) information for physician-administered drugs are being erroneously denied for Edit 800: "HCPCS Requires NDC." In addition, MassHealth has learned that many of these claims are being submitted without the required NDC information. Please check POSC Broadcast Messages for instructions on resubmitting these claims. Please remember that these claims cannot be billed via direct data entry (DDE) on the Provider Online Service Center (POSC) at this time.

For more information please visit www.mass.gov/masshealth click on Information for MassHealth Providers, then on National Drug Code (NDC) Requirements for Physician-Administered Medications or call MassHealth Customer Service at 1-800-841-2900.

** For more information about these notices or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices

** For more information about these notices or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices

August 28, 2009

Important Message about Replacement Claims Transactions

Claims adjustments can be done electronically using the HIPAA-compliant 837 or direct data entry (DDE) format as a replacement transaction. Replacement transactions correct previously paid claims and are not meant to be used for resubmitting denied claims. The replacement claim should include all corrections as well as the full amount requested, not the difference between what was paid previously and what you are expecting now. For HIPAA-compliant 837 formats, submit the corrected claim as a replacement Frequency Code 7. For DDE formats, hit the Replace button, correct the claim and click on the Submit button. This procedure can be used to change any field on the claim except for changes to the Member Number, Pay-to Provider Number, Date of Service, or Claim Type. MassHealth recommends that you share this information with your software vendor or electronic billing intermediary. For additional information, consult the applicable MassHealth Companion Guides on the MassHealth Web site at www.mass.gov/masshealth/newmmis. Click on Need Additional Information or Training then on Updated Billing Guides, Companion Guides, and Other Publications.

Nursing home providers submitting TPL claims no longer need to include non-Explanation of Benefits (EOB) attachments. Instead, MassHealth advises that you keep any TPL attachments such as Medicare Advanced Beneficiary Notices, Insurer UR Notices, Medicare Notices of Non-Coverage on file. For TPL purposes, Patient Status code or Condition codes are no longer used. Using these obsolete codes may cause your claims to deny. Providers must now submit electronic or paper TPL claims using the correct Adjust Reason code. Please follow the billing instructions listed in Transmittal letter (TL) NF-54 (April 2009). In addition, paper submissions must bill with a completed TPL Exception Form for Nursing Facilities and All Inpatient Hospitals. The TPL Exception Form is located on the Mass Health Web site at www.mass.gov/masshealth. Click on Mass Health Regulations and Other Publications, then on Provider Library, and then on Mass Health Provider Forms.

To all Nursing Facility and Rest Home Providers

Nursing facility and rest home providers who bill for Medical Leave-of-Absence (MLOA) and Non-medical Leave-of-Absence (NMLOA) using direct data entry (DDE), must enter the appropriate Occurrence Code and choose "BI" as the Occurrence Type from the Extended Services tab. In addition, please remember to complete the From and To date fields. Claims submitted for these services that do not contain this information will be denied. Thank you for your cooperation.

Update: Medicare Part B Crossover Denials for Error 7740

To notify MassHealth of a member’s termination of insurance, you must complete a Third-Party Liability (TPL) Indicator Form. The TPL Indicator Form and the insurer letter must be faxed to the TPL unit at 617-357-7604. Please exclude MCO, Medicare and Medicare Advantage plans. You must specify the termination date of the insurance policy on the TPL Indicator Form. The TPL unit will update the member’s file within five business days. Prior to submitting your claim to MassHealth, please check EVS to verify that TPL information has been updated. If you are submitting a paper claim to MassHealth, do not attach the TPL Indicator Form or the insurance termination letter to your claim.

The TPL Indicator Form may be downloaded at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library, and then on MassHealth Provider Forms.

MassHealth is researching an issue involving HCPC codes that have been denied for Edit 2505: Member Covered by Medicare. Some of these codes will soon be mapped and set to "pay." In addition, MassHealth will reprocess those claims that denied incorrectly with Edit Code 2505 prior to the change to make them payable. MassHealth will communicate at a future time which HCPC codes were affected and when claims will be reprocessed. No further action is required by providers at this time.

** For more information about these notices or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices

However, when submitting adjusted claims using a Legacy TCN, please be sure to include the leading "20" of the TCN. For paper claim adjustments enter an "A" followed by the TCN.

MassHealth thanks you for your patience and cooperation.

** For more information about these notices or any previous notice, please visit www.mass.gov/masshealth/newmmisnotices

For MassHealth Providers Who Submit Institutional Claims for MassHealth, MassHealth and Medicare, and MassHealth and Other Insurance

For MassHealth Providers Who Bill Using the Form CMS-1500

MassHealth ha­­s posted additional CMS-1500 paper billing support documents to both the NewMMIS and e-learning training Web sites. The documents outline fields that need to be entered when filling out a CMS-1500 form for TPL and provide additional instructions for providers who bill using the paper CMS-1500.

These paper billing support documents have been added as Special Instructions for Submitting Claims on the CMS-1500 for Members with Medicare Coverage and Special Instructions for Submitting Claims on the CMS-1500 for Members with Commercial Insurance to the e-learning Web site at http://masshealthnewmmisprovidertraining.ehs.state.ma.us/.

The documents are located in course POSC - Submitting Professional Claimsunder the heading Course Materials.

The documents have also been added to the NewMMIS Web site, http://www.mass.gov/masshealth/newmmis. Click on Need Additional Information or Training? Then, click on Updated Billing Guides, Companion Guides, and Other Publications. The documents are located under the heading Billing Guides as Special Instructions for Submitting Claims on the CMS-1500 for Members with Medicare Coverage and Special Instructions for Submitting Claims on the CMS-1500 for Members with Commercial Insurance.

For MassHealth Providers Who Submit TPL Exception Claims for Home Health Agencies or for Chronic and Rehabilitation Hospitals:

These job aids have been added as: TPL Exception Claim Submission for Home Health Agencies and TPL Exception Claim Submission for Chronic and Rehabilitation Hospitals to the e-learning Web site at http://masshealthnewmmisprovidertraining.ehs.state.ma.us/.

The job aids are located in course POSC - Submitting Institutional Claimsunder the heading Course Materials.

In calculating the difference between the MassHealth allowable amount and the Medicare payment, NewMMIS will look to see if MassHealth has adopted the Medicare code or has a comparable code for the service and look at the rate for the applicable code. MassHealth will not pay for non-covered services.

However, MassHealth will pay co-insurance and deductibles for services that are covered by Medicare and would not otherwise be covered by Medicaid when the service is provided to a MassHealth member who is eligible for coverage of Medicare coinsurance and deductibles.

Beginning in July 2009, some claims began paying zero inappropriately with EOB code 9928:COB-TPL Cost Savings. MassHealth is pleased to inform you that it has resolved the issue. Affected claims are being reprocessed. No further action is required by providers at this time. If you have questions, contact MassHealth Customer Service at 1-800-841-2900.

In July, MassHealth advised providers that certain claims submitted as adjustments with the Legacy MMIS Transaction Control Number (TCN) were denying inappropriately and that providers should hold such submissions pending further notice.

MassHealth is pleased to inform providers that this issue has been resolved and that providers can now submit claims as adjustments with the Legacy MMIS TCN.

MassHealth thanks you for your patience and cooperation.

Notice Concerning Acute Outpatient NewMMIS Claims Filed with an Institutional Form or Transmission

Update Regarding NewMMIS Claims Denied for Error Code 1945

Claims processed in NewMMIS for week ending July 24 that denied in error for edit "1945-MULT SAK PROV LOCS FOR BILLING PROV SPEC" may now be rebilled to MassHealth. The error, caused by a change to the MassHealth NPI crosswalk that resulted in denials for providers that bill with a single NPI but who have multiple service locations, has been resolved. We apologize for the inconvenience. ;Providers who receive this error message appropriately should contact MassHealth Customer Service at 1-800-841-2900 to discuss claim submission options.

** For more information about this notice or any previous notices, please visit www.mass.gov/masshealth/newmmisnotices

MassHealth will reprocess claims that denied for error codes 2502, Member Covered by Other Insurance, or 2505, Member Covered by Medicare for Billed Procedure Codes S5160 and S5161, on a future RA. Please do not resubmit these claims. No further action is required by providers. New third party liability (TPL) claims submitted to MassHealth for these services will not receive error 2502 or 2505. If you have questions, please call MassHealth Customer Service at 1-800-841-2900.

** For more information about this notice or any previous notices, please visit www.mass.gov/masshealth/newmmisnotices;

Some providers may have experienced a delay in the processing of their TPL paper claims (Commercial and Medicare) due to a lack of submitting required information on the claim form. MassHealth has addressed the issue for the majority of the affected claims. Providers should begin to see their TPL claims process on future remittance advices. As a reminder, it is important that you enter the carrier code on your claim form. If there are multiple payers, indicate the carrier code on each explanation of benefits (EOB). Please refer to Appendix C of your MassHealth provider manual for a list of MassHealth carrier codes. The provider manuals can be found in the Provider Library at www.mass.gov/masshealth/masshealthpubs. If you have questions, please call Customer Service at 1-800-841-2900.

Please be advised that claims for physician-administered drugs that require NDC information cannot be received as direct data entry (DDE) claims in the Provider Online Service Center. These claims must be submitted on paper using the CMS-1500 claim form or electronically using an 837 transaction.

For general information about billing these claims, please see the appropriate billing or companion guide or go to www.mass.gov/masshealth and click on MassHealth and HIPAA, then on Electronic Data Interchange (EDI) and HIPAA Information for Providers, then on the MassHealth Companion Guides link, and choose the 837P/837I Companion Guide or UB-04 or CMS-1500 Billing Guide.