MassHealth

Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Office of Medicaid 
www.mass.gov/masshealth 

Electronic Claims Waiver Request 

Applicant Information 
(Provider Name:) 


Provider Name: 

Address:


 Street Address
 City
 State
 ZIP 
 Contact Name: 
 Contact Number: (      )


MMIS PID/SL (List all individual service locations if applicable.): 
NPI: 
Fax: (     )
Email (if available):

Waiver Request Information 

This is a request for an electronic claims waiver that will be reviewed by 
MassHealth. This policy does not apply to claims submitted on the current 
American Dental Association claim form. 

Please check all the reasons that are preventing you from submitting electronic 
claims.

Low volume of claims (20 or fewer per month) 
Provider software
MMIS issues
Lack of Internet access
Natural disaster
Reasonable accommodation
Other extenuating circumstances

Please provide more information below so that we can make electronic claim 
submission easier for you in the future.






Authorized Signature
Date
Print Name
Title

Please return the completed waiver request form to: 
MassHealth Customer Service, P.O. Box 9118, Hingham, MA 02043, 
fax to 617-988-8910, or e-mail to providersupport@mahealth.net. 

ECWR (11/11) 



MassHealth Claims Submission Policy and Waiver 


To reduce costs and to promote environmental responsibility, MassHealth has 
initiated a paper claim elimination project. As of January 1, 2012, MassHealth 
is no longer accepting paper claim submissions from providers unless they are 
approved for a waiver. This policy does not apply to claims submitted on the 
current American Dental Association claim form. 

MassHealth has developed an annual electronic claim waiver process whereby 
affected providers may apply for an exception to the mandatory electronic claim 
submission policy. The waiver process allows providers who meet certain 
criteria to continue to submit paper claims. 

The criteria to determine eligibility for the waiver include the following. 

1. Low volume of claims – Less than an average of 20 claims per month over the 
previous 12 months 
2. Provider software – Temporary technical difficulties related to upgrading a 
current system or installing 
a new system 
3. MMIS issues – Temporary technical difficulties related to testing or 
interfacing with MMIS 
4. Lack of Internet access – Providers who do not have Internet access or a 
computer 
5. Natural disaster – Temporary disruption in service, of at least five 
business days, caused by natural disaster or utility work 
6. Reasonable accommodation – Provider's staff responsible for claims 
submission have a disability that prevents the submission of electronic claims 
that cannot be easily mitigated with reasonable accommodation 
7. Other extenuating circumstances – Any situation in which complying with this 
policy would impede the ability of the provider to participate in MassHealth 

The approved waiver will expire after 12 months of issuance. If you need to 
reapply for an extension, you must reapply with a new form at least 30 days 
prior to expiration. There will be no charge for the waiver for the first year. 
Every subsequent year for which a waiver is requested, the provider may be 
charged an administrative fee based on paper claim volume. 

MassHealth will respond to your request within 30 calendar days of receipt. 

If you have any questions, please contact MassHealth Customer Service at 1-800-
841-2900 or at providersupport@mahealth.net.