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


TPL Attachment Form

Instructions for Using This Form

1.	Complete this form when the insurer/payer has bundled or unbundled the payments 
	for a set of services.

2.	Use the claim adjudication details provided by the insurer/payer to complete the 
	claim line fields. 

3.	Submit this form only with CMS-1500 and UB-04 claim forms. 

4.	The claim line number on the TPL attachment form must correspond to the CMS-1500 
	or UB-04 claim form line number.
	Please Note: For CMS-1500, a maximum of the first six lines can be used.

5.	Complete all fields on this form.
	Please Note: MassHealth-assigned carrier codes may be found in Appendix C 
	(Third-Party-Liability Codes) of your MassHealth provider manual at 
	www.mass.gov/masshealth. Additionally, all service detail lines billed on the 
	claim should be reported on the form with other insurer/payer information.

MassHealth Provider ID and Service Location: __________________	
NPI: __________________________________	
MassHealth Member ID: __________________________________
Member Name: __________________________	
Dates of Service From: ______________________	
Through: _____________________________
Carrier’s EOB Date:______________________________ 	
Carrier Code: _________________________	
Carrier Name: __________________________

Line No.
Rev. Code
HCPC Code
Payer Paid Amt.
Payment Bundled Into Line Number
Deductible Amt. (PR1)
Coinsurance Amt. (PR2)
Copay Amt. (PR3)
Psych. Reduction Amt. (PR122)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

TPL-AF (Rev. 12/11)