Vendor Session Questions and Answers

General

Q:
When will MassHealth begin to accept HIPAA 5010 production files?
A: 
January 1, 2012
Q:
What are the “Pass” criteria for submitting HIPAA 5010 production files?
A:
Submitters must have a majority of their claims in the Paid status, in the 4010 
production 
environment.
Q:
Will MassHealth test by specialty type?
A:
MassHealth will test all scenarios that cover a cross section of all our 
provider types.
Q:
Will MassHealth test only with billing intermediaries?
A:
MassHealth will test with all trading partners that have submitted transactions 
directly to 
MassHealth within the last 12 months.
Q:
Do we have to submit only claims with NPIs during testing?
A:
All claims must use the NPI where required.
Q:
Will MassHealth issue 835s more frequently during testing?
A:
835s will be issued at a minimum on a weekly basis during our testing phases.
Q:
Will MassHealth test 276 transactions?
A:
Yes. Please refer to our Web site at www.mass.gov/masshealth/5010 to understand 
the full 
scope of our testing.
Q:
Does MassHealth have a disaster plan in place in case we are not ready to go on 
01/01/2012?
A:
MassHealth will be ready for 01/01/2012. We will leverage our previous 
experience with 
the implementation of NewMMIS to ensure we meet this date. Contingencies will be 
invoked as required.
Q:
Will MassHealth be accepting dual transactions?
A:
No.
Q:
How will testers know the status of their test submissions? 
A:
A 999 acknowledgement will be available for all successful test file 
submissions. 
Additionally, MassHealth will outreach to testers directly by phone or e-mail to 
communicate the status of the test file. If you are testing 837 transactions, 
you can also 
review the status of your claims by performing a claim status inquiry in our 
5010 test 
environment.
Q:
Will there be a separate contact number for any questions about 5010 
transactions?
A:
Yes. The number will be provided to the participants involved in that testing 
phase when the 
testing phase begins.
Q:
What is the time frame for 5010 testing?
A:
5010 testing will be conducted from July 2011 through December 2011.
Q:
Will the zip code allow us to enter the leading zeros or will we have to enter 
the correct four 
digits?
A:
The first five digits must be a valid zip code.  The last four digits can be 
zeros, while valid 
numbers are preferred.
Q:
Will MassHealth test coordination of benefits (COB) transactions?
A:
Yes.

 
837I

Q:
In Section 3.8.2 of the 837I Companion Guide, the element CL101 was changed with 
A2, to 
be “Priority (Type) of Admission or Visit” rather than “Admission Type Code,” 
but the 
code set used has stayed the same.
A:
MassHealth will update the companion guide based on what the Addendum reflects.
Q:
In Section 3.8.2 of the 837I Companion Guide, the element CL102 was changed with 
A2, to 
be “Point of Origin for Admission or Visit” rather than “Admission Source Code,” 
but the 
code set used has stayed the same.
A:
MassHealth will update the code set based on what the Addendum reflects.
Q:
In Section 3.8.2 of the 837I Companion Guide, for the element 2310 NM109, it 
states 
“Enter NPI.” Should we enter the value “NPI” or the provider's NPI?  
A: 
Providers should enter their NPI number in NM109. MassHealth will update the 
companion 
guide to clarify this.
Q:
We currently do not submit a diagnosis code, but it is required on all 5010 
claims. Do we 
need to submit one?   
A: 
5010 submissions require a diagnosis code on all claims. If a diagnosis code is 
not 
submitted, it will fail HIPAA compliance and the claim will not process.
Q:
Should we test the ability to void and replace claims?
A:
Testing should reflect your normal business activity with MassHealth. If that 
normal 
business activity includes voiding and replacing claims, you should test this 
functionality.
Q:
The Patient Reason for Visit field (2300 HI01-1=PR) is required for all 
outpatient claims, 
but I do not see any reference to the segment in the companion guide.
A:
MassHealth defers to the requirements as stated in the 837I Implementation 
Guide. This 
field is required when the claim involves outpatient visits.

270/271

Q:
In Section 2.2, Paragraph 3 of the 270/271 Companion Guide, the first sentence 
states that if 
the provider sends all the data elements in the 270, then MMIS will process the 
inquiry 
based on the order mentioned above (ID, SSN, Name/DOB/Gender). However, the very 
next statement reads, “If all data elements are provided, a search will be made 
using only 
the Member Identifier...MMIS will not perform multiple searches based on the 
data 
provided in the 270 request.” 
A:
MassHealth performs searches in a hierarchical manner. If all data elements for 
a search are 
entered, the Member ID is used to find a match. If no match is found then it 
attempts to 
search by the secondary search elements to find a match.
Q:
In Section 3.2.1 of the 270/271 Companion Guide, there is reference to PRV02 
being 
“PXC.” Does this mean that MassHealth requires the taxonomy for the Submitting 
Provider?
A:
The 270/271 Implementation Guide states that, “If not required by this 
implementation 
guide, may be provided at sender’s discretion but cannot be required by the 
receiver.” This 
field is not required by MassHealth for this transaction type.
Q:
In Section 3.2.3 of the 270/271 Companion Guide, for Other Insurance - 2110C 
REF, 
MassHealth states that they will return the Other Insurance Policy Holder's name 
when 
REF01 = IL. However, according to Technical Report 3 (TR3), REF03 I “Required 
when 
REF01 = 18, 6P, or N6, and a name needs to be associated with the corresponding 
identifier. If not required by this implementation guide, do not send.”
A:
MassHealth will update the 270/271 Companion Guide to change possible qualifier 
value of 
GP to 6P, as well as the value for Qualifier of 1L to “other insurance 
policyholder name.”  
A6 will be removed as a qualifier for 5010.
Q:
Copay Cap Pharmacy/NonPharmacy uses EB01=D.  What is the difference between 
CoPayt 
(EB01=B) and this?
A:
This is a feature that MassHealth has displayed since 4010 implementation. The 
EB01=D 
value indicates if a member has met their copayment cap amount. EB01 represents 
the 
copayment required.
Q:
Appendix D indicates that you process true batch requests through the Provider 
Online 
Service Center (POSC). How about via the Healthcare Transaction Service (HTS) 
Web 
service?
A:
True batch requests are currently processed only through the POSC.
Q:
For the other insurance plan 2110C loop, is the insurance plan name indicated 
for EB05, the 
same as indicated for the 2120C NM103 within the same EB loop?
A:
No. NM103 should contain the Plan Name and EB05 should contain the Type of 
Coverage.
Q:
The long term care 2110C loop is using the EB01 value of X. Where is the 
documentation 
for the coded value that is being sent in EB05?
A:
The coded value being sent is documented in the 270/271 Companion Guide. It 
includes the 
Management Minutes Category (MMC) and Management Minutes Questionnaire (MMQ) 
score in the 2110C section, under the Long Term Care portion of the response.  
Q:
For the patient paid amount 2110C loop, which is using the EB01 = G for Out of 
Pocket 
(Stop Loss), this value is usually sent as a limit at which point the insured is 
no longer 
paying out of pocket. If the patient paid amount is being sent with this loop, 
how will the 
provider know what the recipient’s stop loss limit is?  
A:
MassHealth returns a copay cap response as well. (See next question.) 
Q:
For the copay cap status pharmacy 2110C loop, which is using the EB01 = D for 
benefit 
description, the EB05 description (“copay cap status pharmacy”) does not include 
a 
description of the benefit. How will the provider know the meaning of “met” and 
“not met” 
without a description?
A:
Value of “met” and “not met” are to indicate if a member has met the cap for 
copayments or 
has not met that cap. MassHealth will update the companion guide with further 
clarification.
Q:
Is the minimum set of service types identified for the 5010 Technical Report 3 
(TR3) going 
to be returned?
A:
Yes.
Q:
For the behavioral health 2110C loop, which is using EB01 = W for other source 
of data, 
this appears to be an unexpected use of the code as this code is typically used 
to identify an 
entity that has supplied information related to the benefits being identified. 
A:
MassHealth defines the code of W – Other Source of Data, as behavioral health.


276/277

Q:
In Section 3.2.2 of the 276/277 Companion Guide, 2100B NM108 states that you 
expect it 
to be either XX or SV. However, these are no longer valid values under the 5010 
mandate. 
It must be 46, which is the ETIN. What does MassHealth expect for NM109 in this 
case?
A:
MassHealth will update the companion guide to reflect the qualifier of 46. NM109 
- 
Information Receiver Electronic Transmitter Identification Number (ETIN) is your 
10-
character Submitter ID or your 10-character Provider ID/Service Location.
Q:
In Section 3.2.2 of the 276/277 Companion Guide, can you please clarify what 
2200D 
TRN02 is?
A:
This value reflects the Claim Status Tracking Number, which MassHealth will echo 
in the 
277 based on the 276.
Q:
In Section 3.2.2 of the 276/277 Companion Guide, descriptions for 2200D REF01/02 
seem 
to be out of sync.
A:
A value of "1K" in REF01 is the Payer Claim Control Number.
Q:
In Section 3.2.2 of the 276/277 Companion Guide, 2200D DTP01 = type…, should be 
“472” not “232472.”
A:
MassHealth will update the companion guide to reflect the correct value. 
Q:
Section 3.2.2 of the 276/277 Companion Guide refers to 2210D SVC01-1. Does this 
mean you are able to support line level inquiries? If so, how does that work and 
what are the required elements?
A:
MassHealth will remove this, as we do not use this loop.