This job aid contains supplemental billing instructions for submitting 837I transactions, direct data 
entry claims (DDE), or paper claims for dually eligible members (Medicare and MassHealth) who have 
active MassHealth coverage and active Medicare Part B coverage, but no active Medicare Part A 
coverage.
These MassHealth billing instructions supplement the instructions found in the HIPAA 837I 
Implementation Guide, MassHealth 837I Companion Guide, or in the MassHealth Billing Guide for the 
UB-04.  
MassHealth requires all claims to be submitted in an electronic format unless the provider has received 
an approved electronic claim submission waiver. Refer to All Provider Bulletin 217.
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).
To ensure that MassHealth is the payer of last resort, generally providers must make diligent efforts to 
obtain payment from other resources before billing MassHealth. See MassHealth regulations at 130 
CMR 450.309 through 450.321.
Billing Instructions for 837I Transactions 
The following table contains the critical loops and segments required for submitting Inpatient claims to 
MassHealth for dually eligible members who have active MassHealth coverage and active Medicare 
Part B coverage, but no active Medicare Part A coverage. Providers must complete the loops and 
segments as described in the following table and follow instructions described in the HIPAA 837I 
Implementation Guide and MassHealth 837I Companion Guide to complete other required COB and 
non-COB portions of the 837I claim submission.

Loop
Segment
Value Description
2320
SBR09 (Claim Filing Indicator)
MB
2320
AMT01 (Paid Amount Qualifier)
D
2320
AMT02 (Paid amount)
Medicare Part B paid amount
2330B
NM109 (Other Payer Name)
0085000
2330B
DTP01 (Date Claim Paid Qualifier)
573
2330B
DTP03 (Check or Remittance Date)
Medicare’s payment date

Note: For COB balancing, the sum of the claim level Medicare Part B payer paid amount and HIPAA 
adjustment reason code amounts must balance to the claim billed amount. Providers should report a 
claim adjustment segment (CAS) with the appropriate HIPAA adjustment reason code and amount on 
their Medicare Part B payer loop. 



Billing Instructions for Direct Data Entry (DDE)
Providers must enter information in the fields given below for submitting inpatient claims to 
MassHealth for dually eligible members who have active MassHealth coverage and active Medicare 
Part B coverage, but no active Medicare Part A coverage. Providers must follow instructions in the 
MassHealth billing guides to complete other required COB and non-COB data fields of the DDE claim 
submission that are not specified in the following table. 
On the Coordination of Benefits Tab
On the List of Coordination of Benefits (COB) panel:
1.	Click New Item. The Coordination of Benefits (COB) Detail panel displays.
On the Coordination of Benefits (COB) Detail panel:
2.	In the Carrier Code field, enter 0085000.
3.	In the Carrier Name field, enter Medicare B.
4.	In the Remittance Date field, enter the Medicare Part B remittance payment date.
5.	In the Payer Claim number field, enter the Medicare claim number from the EOMB.
6.	In the Payer Responsibility field, select the appropriate code from the drop-down list. 
7.	In the COB Payer Paid Amount field, enter the Medicare Part B paid amount.
8.	Do not enter a value in the Total Noncovered Amount field. The total noncovered amount should 
only be entered for authorized TPL exception billing. Refer to supplemental instructions in your 
provider manual appendix for conditions for which this field may be used.
9.	Do not enter a value in the Remaining Patient Liability field. This is not a required field and is not 
necessary for claims adjudication.
10.	In the Claims Filing Indicator field, select MB - MEDICARE PART B form the drop-down list.
11.	In the Release of Information field, select the appropriate code from the drop-down list.
12.	In the Assignment of Benefits field, select the appropriate code from the drop-down list.
13.	In the Relationship to Subscriber field, select the appropriate code from the drop-down list.
14.	If you selected “18 – SELF” from the “Relationship to Subscriber” drop down list, then click 
“Populate Subscriber.” The following data fields that have been entered on the “Billing and 
Service” tab will be populated.
*	Subscriber Last Name
*	Subscriber First Name
*	Subscriber Address 
*	Subscriber City
*	Subscriber State
*	Subscriber Zip Code
If you select any other value from “Relationship to Subscriber” drop down list, you must enter the 
following required fields.
*	Subscriber Last Name
*	Subscriber First Name
15.	In the Subscriber ID field, enter the other insurance subscriber ID number.



Billing Instructions for Paper Claims
MassHealth requires all claims to be submitted in an electronic format unless the provider has received 
an approved electronic claim submission waiver. Refer to All Provider Bulletin 217.
Providers must follow the instructions in the MassHealth Billing Guide for the UB-04. Attach the 
Medicare Part B Explanation of Medicare Benefits (EOMB) to the UB-04 claim form and follow these 
instructions. 
*	Circle the applicable EOMB information that corresponds to the claim.
*	Write the carrier code 0085000 on the EOMB.
MMIS POSC Job Aid: Supplemental Instructions for 
Submitting Inpatient Claims for MassHealth Dually 
Eligible Members with Medicare Part B Coverage Only

MassHealth Provider Online Service Center	1 of 3	Effective December 1, 2012 v1.6