Remittance Advice Request Form 
Remittance advices are available for download at no cost from the Provider Online Service Center (POSC) for six months from the date of issuance. Providers may use this form to purchase a copy of a remittance advice on paper or CD. Copies of remittance advices may be purchased even after they are no longer 
www.mass.gov/masshealth 
available for download from the POSC. 
Provider Contact Information 
Provider (Legal Name)  Tel. no.  
Provider Remittance Address  City  State  Zip  
NPI or Provider ID/Service Location  Note to Group Practices: If you bill under individual provider numbers, please indicate the individual provider number, not the group practice provider number.  

List Run Numbers per Service Location 

Provider ID/Service Location  Run Number  








Name of individual completing the form: 
Calculate Fee 


Requested Media Type (Check one.)
 Paper copy 
PDF file on CD 
Mail Form 
Make check payable to Customer Service Correspondence. Attach check to form and mail to the following address. MassHealth Remittance Advice Correspondence 
P.O. Box 45 
Boston, MA  	02112-0045 Title: 
Signature: 	By signing this form, you are certifying that you are authorized to complete this form on behalf of the provider. 
Phone no.: E-mail address: 	Date: 
Additional Instructions and Information 
Fees 
There is a fee of $10 for every remittance advice (RA) request per provider ID/service location. This fee covers the cost of labor and materials required to produce and mail a copy of a remittance advice of up to 200 pages or one CD. For paper remittance advices that exceed 200 pages or electronic copies that require more than one CD, MassHealth will apply an additional fee of $3 per 200 pages or additional CD. 
Processing Time Frames 
Requests for paper remittance advices that are fewer than 200 pages or electronic copies that can be contained on a single CD are processed within five business days of receipt of the form and check. If your requested paper copy exceeds 200 pages or your requested electronic copy requires two or more CDs, a MassHealth Customer Service representative will contact you for the additional fee. MassHealth will process the remittance advice request within three to five business days of receiving the additional fee. 
Remittance Advice Mailing Address 
Copies of remittance advices will be sent to the remittance address that MassHealth has on file. 
Electronic Remittance Advice 
Providers will have access to the PDF remittance advice and the HIPAA-compliant 835 remittance advice for six months via the Provider Online Service Center, and should not need to request copies of their remittance advices through MassHealth, unless they did not download their original remittance advice within the first six months or they lost their original. 
If you are interested in learning more about the PDF remittance advice and the 835 transaction, or if you have additional questions, please go to www.mass.gov/masshealth, or contact MassHealth Customer Service at 1-800-841-2900. 
R-RA (Rev. 06/09)