MMIS POSC Job Aid: 
Professional Claims Submission with MassHealth


This job aid reviews the process of submitting an electronic professional claim in the Provider Online Service 
Center (POSC). For specific billing information, providers should reference the relevant Billing Guides, available 
at: www.mass.gov/masshealthpubs (click the Provider Library to access a specific guide).
Please Note: A previously submitted electronic claim that requires a correction to the procedure code, revenue 
code or service date must be submitted via Direct Data Entry (DDE).
Professional claims are used when submitting a claim for services provided at a physician’s office. This job aid 
describes how to:
*	Enter a single professional claim for a member who has MassHealth (Medicaid) Insurance.

Submit MassHealth Claim
From the MassHealth Provider Online Service Center:
1.	Click Manage Claims and Payments to submit the professional claim.
2.	Click Enter Single Claim. The Claims Templates panel displays.                                                 
Claims Templates
On the Claims Templates panel:
3.	Click Professional Claim. The Billing Information panel displays.
Note: The Billing Information panel opens under the Billing and Service tab. This tab plus the 
Extended Services and Coordination of Benefits tabs make up the Claim header.
Billing Information: Billing Information
On the Billing Information panel:
4.	Select the Billing Provider ID from the drop-down.
5.	Enter the Member ID.
6.	Enter the Patient Account #.
7.	Enter the member’s Last Name.
8.	Enter the member’s First Name.
9.	Select the member’s Gender from the drop-down.
10.	Enter the member’s DOB.
11.	Enter the Member (Street) Address.
12.	Enter the Member City.
13.	Enter the Member Zip.
14.	Select the Member State from the drop-down.



Billing Information: Billing Information (Continued)
15.	Select the Release of Information option from the drop-down.
16.	Select the Place of Service from the drop-down.
17.	Select the Assignment of Benefits Ind option from the drop-down.
18.	Select the Signature on File option from the drop-down.
19.	Select the Provider Accepts Assignment option from the drop-down.
20.	Select the Claims Filing Indicator from the drop-down.
Billing Information: Service Information and Claims Charges
21.	Enter the Diagnosis Codes (minimum of one required).
22.	Enter the Total Charges.
23.	Click the Extended Services tab.
Note: Clicking the Extended Services tab will save data entered so far and will check for any required 
fields that have not been populated with information. 




Extended Services: Extended Services Information and Service Facility Provider
On the Extended Services Information panel:
24.	Enter or select the following, as appropriate:
*	CLIA Number
*	IDE Number
*	EPSDT Condition Indicator 1
*	EPSDT Condition Indicator 3
*	Birth Weight
*	Last Menstrual Period
*	Estimated Date of Birth
*	Mammography Cert.
*	Homebound Indicator
*	EPSDT Referral
*	EPSDT Condition Indicator 2
*	Pregnancy Indicator
*	Delay Reason Code
*	Last X-Ray
*	Hearing / Vision Prescription 

When submitting a 90-Day Waiver Request enter one of the following Delay Reason Codes:
1-Proof of Eligibility Unknown or Unavailable
4-Delay in Certifying Provider
8-Delay in Eligibility Determination

When submitting a Final Deadline Appeal Request enter Delay Reason Code 
9-Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation
 
When submitting a NCCI/MUE Review Request or a Special Handle claim enter Delay Reason Code
11-Other.

On the Service Facility Provider panel:
25.	Enter the Service Facility Provider Name.
26.	Enter the Service Facility Provider NPI.




Extended Services: List of Claim Notes
On the List of Claim Notes panel:
27.	Click New Item. The Claim Notes Detail panel displays.
Note: A maximum of 10 claim notes can be added to a claim.
On the Claim Notes Detail panel:
28.	Select the Claim Note Type.
29.	Enter the Claim Note Description.
30.	Click Add. 

Extended Services: Ambulance Transport and Certification
On the Ambulance Service panel:
31.	Enter or select the following, as appropriate: 
*	Patient Weight
*	Transport Reason Code
*	Transport Distance
*	Roundtrip Purpose Description 
*	Stretcher Purpose Description
*	Certification Condition Ind 

Procedure
Note:  If there were a third party to bill, you would complete the Coordination of Benefits panel before adding 
the Procedure information. 
32.	Click New Item. The Professional Services Detail panel displays. 







Procedure: Professional Services Detail
On the Professional Services Detail panel:
33.	Enter the HCPCS Procedure Code.
34.	Enter modifiers when applicable.
35.	If billing for an unlisted Procedure Code, enter a description of service – up to 80 characters.
36.	Enter the From Date of Service.
37.	Enter the To Date of Service.
38.	Select the Place of Service from the drop-down.
39.	Enter the Diag. Cross-Ref.
40.	Enter the Charges.
41.	Enter the Units.
42.	Select the Units of Measurement from the drop-down.
43.	Select the Emergency option from the drop-down.
44.	Select the EPSDT option from the drop-down.
45.	If the claim includes charges for a National Drug Code (NDC), complete the following fields, as 
appropriate.
*	NDC – enter the complete ID 
number of drug
*	Units
*	Units of Measurement
 
*	Rx Qualifier
*	Rx Number
*	Rx Date
Note: If this completes the procedure information, click Add at the bottom of the panel.  If not, scroll 
down to continue entering information. 

Professional Services Detail: DME Service
46.	If the claim includes Durable Medical Equipment (DME) service, complete the following fields, as 
appropriate.
*	DME Length of Medical Necessity
*	DME Rental 
*	DME Purchase Price
*	Referral Unit Price Indicator 
Note: If this completes the procedure information, click Add at the bottom of the panel.  If not, scroll 
down to continue entering information.



Professional Services Detail: Ambulance Service
47.	If the claim includes Ambulance services, complete the following fields as appropriate.
*	Patient Weight
*	Patient Count
*	Transport Reason Code
*	Transport Distance
*	Roundtrip Purpose Description 
*	Stretcher Purpose Description
*	Certification Condition Ind
48.	Enter the Ambulance Pick-up Location.
49.	Enter the Ambulance Drop-Off Location.
50.	Click Add.
Note: The information you enter will be added to the List of Professional Services.

Professional Services Detail: List of Notes
On the List of Notes panel:
51.	Click New Item. The Notes Detail panel displays.
Note: A maximum of 10 claim notes can be added to a claim.
On the Notes Detail panel:
52.	Select the Note Type.
53.	Enter the Note Description.
54.	Click Add.
Note: The List of COB Line Items is used when the member also has Other Insurance or Medicare. 

Attachments Tab
On the Attachments tab:
55.	Click New Item. The Attachments Detail panel displays.
On the Attachments Detail panel:
56.	Select the Report Type from the drop-down.
57.	Select the Transmission Code from the drop-down.
58.	Click Browse and navigate to the file.
59.	Select the desired file and click Open.
60.	Click Add/Upload. 




List of Attachments 
On the List of Attachments panel:
61.	Click Confirmation.
 
Confirmation 
On the Confirmation panel:
62.	Confirm the information is accurate.
63.	Click Submit.
Explanation of Benefits (EOB) Codes
On the Explanation of Benefits (EOB) panel:
64.	Review any EOB codes that may appear.
65.	Click Close.

MMIS POSC Job Aid: 
Professional Claims Submission with MassHealth
MassHealth Provider Online Service Center	1 of 7	Revised: October 25, 2011
		v2.7 
Provider Online Service Center - Submit a Referral
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