90-Day Waiver

Request Form 

THE COMMONWEALTH OF MASSACHUSETTS
Executive Office of Health and Human Services 

To submit a 90-day waiver request for claims other than pharmacy and dental, 
please complete this form for every claim and attach applicable supporting 
documentation to each one.

Date of Request:
Provider Name:
Provider Address:
MassHealth Provider ID/Service Location:

Reason for Request

You may request a 90-day waiver when one or more of the following conditions 
apply and the claim is not currently in a pended, paid, or suspended status. 
Please check one or more of the applicable reasons and provide necessary 
documentation with every claim.

The member or provider was retroactively enrolled with MassHealth. Use delay 
reason code 8 for member or 4 for provider.

The member did not inform the provider of the member’s enrollment with 
MassHealth within 90 days of the
date of service. Use delay reason code 1.

The provider is making a change to a procedure or revenue code on a claim that 
was originally submitted on paper within the time limits. Use delay reason code 
8.

The provider is making a change to the member’s MassHealth ID number on a claim 
that was originally submitted within the time limits defined in MassHealth 
regulations at 130 CMR 450.309 and 450.313. Use delay reason code 8.

The provider is making a change to the pay-to-provider number on a claim that 
was originally submitted within the time limits defined in MassHealth 
regulations at 130 CMR 450.309 and 450.313. Use delay reason code 8.

Other. Use delay reason code 8. Please explain:


Please consult the directory in Appendix A of your MassHealth provider manual 
for information on submitting paper 90-day waiver requests.

Copies of this form can be downloaded from www.mass.gov/masshealth. Click on 
MassHealth Provider Forms on the lower right side of the home page. Refer to 
Subchapter 5, Part 7, in your MassHealth provider manual for
additional information on how to submit a 90-day waiver request.

Note: For pharmacy claims, download the 90-day waiver request form from 
www.mass.gov/masshealth/pharmacy. Click on MassHealth Pharmacy Publications and 
Notices for Pharmacy Providers, and then on 90-Day Waiver Form.

90-DWR (Rev. 11/11)