Important. Please Read NewMMIS Notices - by Function

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Due to required system maintenance, the Provider Online Service Center (POSC) will be unavailable for MassHealth claims submission (both DDE and Batch) from Sunday, May 27th 10:00 AM to Monday, May 28th 6:00 AM. The POSC will be available for all other services. If you have questions, please contact MassHealth Customer Service at 1-800-841-2900.

We apologize for any inconvenience this may cause.

Providers are reminded that adjustments can be made to paid claims only. Claims that are denied must be resubmitted to MassHealth for payment. Initial claims must be received within 90 days of the service date (if billing another insurance, 90 days from the date of the explanation of benefits).

If you have a claim in a paid status and want to adjust it, generally, you can submit a replacement claim with additions, deletions, or corrections to any detail lines for up to one year (or 18 months with other insurance) from the date of service (DOS) on the claim if the original DOS remains the same and the original claim was received by MassHealth within the specified 90-day timeframe. When adjusting a paid claim, you must submit all lines (including those that were previously paid).

For more information, visit the FAQs about MassHealth’s Electronic-Claims Policy page on the MassHealth Web site. Go to www.mass.gov/masshealth and click the Information for MassHealth Providers link. Also, since claim processing varies with claim type, please refer to Part 6 (Claim Status and Correction) of the Administrative and Billing Instructions (Subchapter 5) of your MassHealth provider manual for further instruction. Part 6 describes procedures for correcting and rebilling claims by claim type. You can access your MassHealth provider manual from the online Provider Library at www.mass.gov/masshealthpubs.

The Office of the Comptroller and the Office of the State Treasurer have mandated January 1, 2012, as the conversion date for all payments issued by the Commonwealth to be conducted using Electronic Funds Transfer (EFT). Therefore, all MassHealth providers are expected to be paid via electronic payments. If you currently receive payments electronically from MassHealth no further action is required.

If you are already enrolled as a MassHealth provider but do not currently receive electronic payments, you are required to complete the EFT form and return it to MassHealth as soon as possible. Please send only one form per MassHealth provider number. EFT participation is now required when a provider submits a new enrollment application to MassHealth. The EFT Form will be processed upon enrollment.

Individual practitioners who are enrolled/enrolling as part of a group practice and will not submit claims for payment under their individual national provider identifier (NPI) must enroll with MassHealth as a “no pay” provider. EFT is not required. Enrolling as a “no pay” provider also eliminates the requirement of submitting the Massachusetts Substitute W-9, Data Collection Form (DCF), and Trading Partner Agreement. Applicants submitting paper applications should write “no pay” in Section I of the application, to the right of Field 11. Those submitting applications via the Provider Online Service Center (POSC) must include a “no pay” statement when they submit the Provider Agreement.

Applications received without an EFT form or “no pay” designation will be returned to the provider for completion. Documents not returned within the 14-day enrollment period will be denied.

Exceptions to this mandate are not expected.

To receive payment through EFT, you must print and complete the EFT form. You can download the EFT form online from the MassHealth home page (www.mass.gov/masshealth), then click the link MassHealth Provider Forms in the Publications panel, and select EFT/Direct Deposit Application (EFT-1). Please refer to the new online EFT Tip Sheet for important EFT form completion and submission guidelines as well as requirements for documentation that must accompany the EFT form. Go to www.mass.gov/masshealth. Click on Information for MassHealth Providers, then click on Tips for Completing the Electronic Funds Transfer (EFT) Form.

The completed form and required documentation must be mailed to MassHealth Customer Service, ATTN: Provider Enrollment and Credentialing, P.O. Box 9118, Hingham, MA 02043. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900. Dental Providers should mail their signed, completed form and required documentation to DentaQuest, Attn: Customer Service: MassHealth Dental, 12121 N. Corporate Parkway, Mequon, WI, 53092

You must attach a copy of your Notice of Denial from Permedion to every claim you rebill to MassHealth. Permedion conducts MassHealth’s Acute Hospital Utilization Management program. The rebilled claim and notice should be submitted to MassHealth using direct data entry (DDE). MassHealth will not accept a paper rebilling, unless the hospital has an approved waiver to submit paper claims. All rebilled claims must be submitted to MassHealth within the timeframe designated in your Notice of Denial from Permedion.

For example, if a claim for an inpatient admission (with dates of service from 4/1/12 through 4/2/12) has been denied and the hospital is rebilling for two days of outpatient services, then the hospital must submit a copy of the denial notice from Permedion for the outpatient services for EACH date of service being rebilled.

For more information about the rebilling process, refer to regulations at 130 CMR 415.414(B)(3). You can access MassHealth regulations from the Publications panel on the MassHealth Web site at www.mass.gov/masshealth. If you have questions, please contact Permedion at 617-398-1407.

When an outpatient service (claim line) has been denied by Permedion, MassHealth’s Acute Hospital Utilization Management contractor, the ENTIRE claim is also voided. To receive payment for the service(s) that were not denied, the hospital must submit a new claim, without the claim lines for the denied service(s), and attach a copy of the Notice of Denial from Permedion. The rebilled claim and notice should be submitted to MassHealth using direct data entry (DDE). MassHealth will not accept a paper rebilling, unless the hospital has an approved waiver to submit paper claims. All rebilled claims must be submitted to MassHealth within the timeframe designated in your Notice of Denial from Permedion. If you have questions, please contact Permedion at 617-398-1407.

Effective March 15, 2012, MassHealth revised its regulations to allow payment to physicians and community health centers for the application of fluoride varnish to children under the age of 21 by medical assistants under the supervision of a physician. Previously MassHealth regulations allowed payment for application of fluoride varnish only by physicians, nurse practitioners, registered nurses, licensed practical nurses, and physician assistants. To qualify to apply fluoride varnish under MassHealth requirements, the individual must complete an online MassHealth approved training on the application of fluoride varnish, maintain proof of completion of the training and provide such proof to MassHealth upon request. You can access the MassHealth approved, self-administered online fluoride varnish application training options, as well as detailed instructions for completing the trainings and the required Proof of Completion Document on the MassHealth Fluoride Training for Health Care Professionals Web page (http://www.mass.gov/eohhs/gov/newsroom/masshealth/providers/fluoride-varnish-training-for-health-care.html).

Once on-line training has been completed, physicians and qualified personnel may schedule an in-office visit with the MassHealth Outreach Coordinator to reinforce how to implement the use of fluoride varnish in your office and how to bill for the service. To schedule an in-office visit, contact the Outreach Coordinator directly at Megan.Mackin@Dentaquest.com or 617-886-1728.

To conform to the National Correct Coding Initiative (NCCI) methodology from the Centers for Medicare and Medicaid Services (CMS), MassHealth began enforcing new NCCI editing guidelines as described in All Provider Bulletin 209 (dated April 2011). MassHealth completed the system implementation for the coding updates at the end of October 2011. This change resulted in certain claims being incorrectly processed between 4/1/2011 and 10/31/2011. MassHealth is reprocessing the affected claims that contained NCCI procedure codes with dates of service between 10/1/2010 and 10/31/2011. The reprocessed claims will begin to appear on this or future remittance advices. If you have questions, please contact MassHealth Customer Service at providersupport@mahealth.net  or 1-800-841-2900.

Pharmacy providers should continue to follow the final deadline appeals process described in Appendix A of the MassHealth Pharmacy Online Processing System (POPS) Billing Guide (www.mass.gov/eohhs/docs/masshealth/pharmacy/pops-billing-guide.pdf).

Please Note: Pharmacy providers billing for durable medical equipment (DME) services using a CMS-1500 claim form should submit final deadline appeals through direct data entry (DDE) via the Provider Online Service Center (POSC) using delay reason code 9. For information and instructions about this process, refer to instructions in All Provider Bulletin 221 (dated December 2011). You can access MassHealth publications from the online Provider Library at www.mass.gov/masshealthpubs.

To check the status of a pending appeal, e-mail your inquiry to FDEAppeals@state.ma.us or call 617-847-3115. 

If you have questions about POPS billing and claims, you can contact the Xerox Technical Help Desk at 1-866-246-8503, 24 hours a day, seven days a week.

MassHealth has identified a system issue that may have resulted in underpayments for claims processed with service code T2046 from 3/5/12 through 3/7/12. The affected claims are being systematically adjusted and should begin appearing on remittance advice 100158 (dated 6/5/12). No further action is required by providers. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

This remittance advice may contain claims that were previously processed and denied at the header with at least one detail denied for edit 5010 (Exact duplicate – outpatient claim). The affected claims, with dates of service from 10/01/09 through 09/30/10, were denied because there were no HCPCS codes included on the line(s) with edit 5010.

For those paid claims with multiple lines, containing lines denied with edit 5010, MassHealth encourages providers to resubmit for consideration ONLY those lines that were denied for edit 5010 AND that contained no HCPCS codes. MassHealth suggests that you resubmit just those high charge lines that would move an episode to outlier in the payment amount per episode (PAPE) calculation. You must send any qualifying claims on a disc to the attention of Lydia Hatch at MassHealth, 100 Hancock Street, 6th Floor, Quincy, MA 02171. Discs must be received by 5/11/12 for consideration.

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

The POSC is a Web-based portal that includes the functions described below. Providers are encouraged to use the POSC to accomplish these tasks independently. Regularly accessing the many online tools available on the POSC can help improve your efficiency when completing the business transactions you need to conduct with MassHealth. From the Online Services panel of the MassHealth home page (www.mass.gov/masshealth), click on Provider Online Service Center.

POSC Functions:

-enroll as a MassHealth provider and manage profile information, such as changes to provider profile (see Manage Provider Information);
-add to and update subordinate accounts (see Administer Account);
-perform direct data entry (DDE) real-time, continuous, interactive claims processing, verify member eligibility, submit batch claim, check claim status, resubmit DDE (see Manage Claims and Payments);
-manage service authorizations: enter, update, and inquire about preadmission screening (PAS), prior authorization (PA), and Primary Care Clinician (PCC) referrals; request nonemergency transportation for members; and upload and download batch service authorizations (see Manage Service Authorizations);
-view publications such as forms for downloading, transmittal letters and bulletins, news, training registration and materials, and MassHealth regulations; access links to mass.gov (news,  publications, related updates) (see Reference Publications);
-view notifications, including any new EOHHS notices, Broadcast Messages, contracts, letters and documents (for example, view PAS, PA and PCC notices), reports, metrics, and financial data; generate financial and claim denial reports; and download remittance advices (see Manage Correspondence and Reporting);
-enroll and disenroll members for Senior Care Options (SCO) and Program of All-inclusive Care for the Elderly (PACE), and submit Management Minutes Questionnaires (MMQ) (see Manage Members); and
-change password and manage Subordinate User accounts (see Administer Account).

Several online job aids offer instruction for these functions. You can access these job aids on the MassHealth Web site (www.mass.gov/masshealth ). Select the Information for MassHealth Providers link, click New Medicaid Management Information System (NewMMIS) and the Provider Online Service Center (POSC). Click Using the POSC for the First Time, and then click Get Trained.

For providers with one national provider identifier (NPI) corresponding to multiple MassHealth Provider ID/Service Locations (PID/SLs), MassHealth uses the doing business as (DBA) address provided on the claim that corresponds to the unique service location to define where services were provided. When correcting paid claims, changing information such as the DBA or provider ID on your claim, will cause the replacement claim to adjudicate to a different service location from the one initially billed and will result in the claim being denied.

If more than 90 days have passed since the oldest date of service on the claim, and you want to change the DBA address, member ID, provider ID or claim type, please refer to the 90-day waiver procedures found in your MassHealth provider manual. You can access your MassHealth provider manual from the online Provider Library at www.mass.gov/masshealthpubs.

MassHealth has identified an issue that resulted in certain outpatient claims for lab services that were submitted with service codes G0431 and G0434 to be bundled into the payment amount per episode (PAPE) when they should have been processed according to the lab fee schedule. The affected claims were submitted with dates of service from 12/1/11 to 4/2/12. MassHealth is reprocessing these claims and the adjustments will begin to appear on this and future remittance advices.

Please Note: Claims that were submitted and paid a PAPE during this time frame will now show the PAPE portion of the payment taken back and the lab fee amount paid. If you have questions, please contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

MassHealth has adjusted FQHC crossover claims with dates of service from 5/26/2009 to 8/29/2011 that were underpaid. The affected claims should begin appearing on this and future remittance advices (RAs). If the visit has been paid on both the institutional and professional claim, then informational Explanation of Benefits (EOB) code 5097 (Same service on professional crossover will be voided) will appear on the RA with the adjusted institutional crossover claim. Providers will be notified when the adjustment of these professional crossover claims has been processed.

Please Note: FQHC institutional crossover claims processed on or after 8/30/2011 have been paid correctly. Providers should continue to check Broadcast Messages and future RAs for updated information about the processing of these FQHC claims. If you have questions, please contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

MassHealth requires providers to obtain prior authorization (PA) for certain services. Please review your MassHealth program regulations for a proposed service to determine when PA is required. Please note that PA requests for certain services require additional forms that must accompany the request. In addition to program regulations, PA requirements may appear in Subchapter 6 of certain provider manuals, in provider bulletins, or in other written issuances from MassHealth. You can access the MassHealth provider manuals and provider bulletins from the MassHealth online Provider Library at www.mass.gov/masshealthpubs.

MassHealth reviews PA requests on the basis of medical necessity only and does not establish or waive any other prerequisites for payment, including eligibility or referral. Please remember to request a new PA for any subsequent request for the same service. The approval of a PA is not a guarantee of payment. You must still verify the member’s eligibility, other insurance, and any other restrictions before providing service. 

MassHealth strongly encourages all providers to request PA using the Provider Online Service Center (POSC) at www.mass.gov/masshealth/providerservicecenter. Providers can submit PA requests, all attachments (including supplemental and paper PA forms), and any subsequent PA requests, as well as review the status of their PA requests, electronically via the POSC. 

MassHealth has noticed an increase in the number of claims being submitted with incomplete or erroneous PA information. Some of the common denials being reported are listed below, followed by suggested resolution tips. Please make every effort to follow these PA guidelines to avoid claim issues.

• Edit code 3003 (Procedure code requires PA): Refer to Subchapter 6 of your provider manual and review the Benefit Administration section of the REFERENCE tab for PA restrictions.
• Edit code 3009 (PA number not on the database): Please ensure that your PA number listed is complete and/or correct. (The PA number can be found on the claim header.)

When you need to contact MassHealth Customer Service for further assistance once you have exhausted all automated options and online resources, please make every effort to be prepared with all essential information needed by the Customer Service staff.  Depending on the nature of your inquiry, the following information is essential and must be readily available when contacting Customer Service:

• provider ID/service location (PID/SL) or national provider identifier (NPI);
• member identification number;
• internal control number (ICN);
• claim status;
• edit or explanation of benefits (EOB) code(s); and
• service codes.

Additionally, have copies of any supporting documentation accessible for quick reference to assist the Customer Service staff to efficiently and effectively respond to your inquiry. Please be sure to review your remittance advice (RA), via the Provider Online Service Center (POSC), for all claims-related inquiries. You can access the POSC from the MassHealth home page at www.mass.gov/masshealth. If you do not have POSC access, contact your primary user at your office or facility.

MassHealth strongly encourages you to visit the MassHealth Web site for POSC instructional aids and other billing and policy resources designed to help you conduct your daily MassHealth business functions and/or to use as references if you encounter any issues or questions. Some of these resources and their online access instructions include the following.

• job aids (From the MassHealth Web site, www.mass.gov/masshealth, select the Information for MassHealth Providers link. Click MassHealth Provider Trainings, and then click NewMMIS Provider Training.)
• MassHealth provider manuals (applicable sections to site related regulations, service codes, etc.) (At www.mass.gov/masshealthpubs, click on Provider Library.)
• transmittal letters or bulletins (At www.mass.gov/masshealthpubs, click on Provider Library.)
• copies of RA message texts (At www.mass.gov/masshealthpubs, click on Provider Library.)
• MassHealth Billing and Companion Guides (Go to www.mass.gov/masshealth/5010.)

Your cooperation is appreciated.

MassHealth has identified an issue that caused some outpatient and medical claims to be denied erroneously with Edit 4801 (Procedure not covered by provider contract). MassHealth has resolved the issue and is reprocessing the affected claims. The reprocessed claims will appear on this or future remittance advices. No further action is required by providers. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

A suspended claim appears on a remittance advice (RA) for information only and requires NO action by a provider. Please do not correct or rebill a suspended claim.

Claims appear in a “SUSPEND” status for many reasons. The most common is that the claim must be manually reviewed by MassHealth to determine the appropriate fee, or the medical necessity of the service. Claims also suspend to allow time for the member eligibility or other files to be updated.

The majority of claims that suspend are adjudicated within 45 days of the suspense date.
Rebilling a claim already in suspense will only cause the subsequent claim submission to suspend as well.

You can track the status of a suspended claim using your internal control number (ICN), which can be found on your RA. To verify the status of a claim submitted to MassHealth for services provided to MassHealth members, you can use either batch HIPAA transaction sets 276/277 or the direct data entry (DDE) panel on the Provider Online Service Center (POSC).

Once the claim has adjudicated, it will appear on a subsequent RA as either “PAID” or “DENIED.” You should contact MassHealth Customer Service (1-800-841-2900) for assistance with your suspended claim only if your claim does not appear on your RA as adjudicated within 45 days of the suspension notice.

A suspended claim appears on a remittance advice (RA) for information only and requires NO action by a provider. Please do not correct or rebill a suspended claim.

Claims appear in a “SUSPEND” status for many reasons. The most common is that the claim must be manually reviewed by MassHealth to determine the appropriate fee, or the medical necessity of the service. Claims also suspend to allow time for the member eligibility or other files to be updated.

The majority of claims that suspend are adjudicated within 60 days of the suspense date.
Rebilling a claim already in suspense will only cause the subsequent claim submission to suspend as well.

You can track the status of a suspended claim using your internal control number (ICN), which can be found on your RA. To verify the status of a claim submitted to MassHealth for services provided to MassHealth members, you can use either batch HIPAA transaction sets 276/277 or the direct data entry (DDE) panel on the Provider Online Service Center (POSC).

Once the claim has adjudicated, it will appear on a subsequent RA as either “PAID” or “DENIED.” You should contact MassHealth Customer Service (1-800-841-2900) for assistance with your suspended claim only if your claim does not appear on your RA as adjudicated within 60 days of the suspension notice.

Nursing facility providers: Please review the recent message text below to hospice providers regarding automated pricing for hospice room and board claims in nursing facilities.

HOSPICE PRICING FOR SERVICE CODE T2046
MassHealth recently implemented automated pricing for hospice services on claims submitted with Service Code T2046 (Hospice long term care, room and board only; per diem) for members receiving hospice services in a nursing facility. MassHealth’s claim processing system is now able to calculate the correct payment for the member’s casemix score and the nursing facility’s rate for that casemix score, multiplied by the number of units at 95 percent, less any applicable patient paid amount (PPA). Hospice providers should continue to bill for services using Service Code T2046 as usual.

Nursing facility providers please also be sure to submit your Management Minutes Questionnaires (MMQ) in accordance with the instructions in MassHealth Transmittal Letter NF-53 (dated May 2009). If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

As directed under 130 CMR 437.412(C), hospice providers must submit a completed and signed MassHealth Hospice Election Form according to the form’s instruction, before billing for MassHealth members who elect hospice services. This form must be completed whenever a MassHealth member chooses to elect or stop hospice services, to disenroll from hospice services, or to change hospice provider.

If you do not submit a completed and signed Hospice Election Form the member will not be properly coded to the hospice provider’s ID/service location (PID/SL). Claims submitted by a hospice provider for members who are not coded under the hospice provider’s PID/SL will be denied with edit 2800 (Member not tied to hospice for date of service).

Please note: A completed Hospice Election form includes (but is not limited to)

-MassHealth PID/SL;
-MassHealth member ID; and
-insertion of hospice disenrollment reason (section D, if applicable)

To download a copy of the MassHealth Hospice Election Form (HOS-1) from the MassHealth Web site homepage (www.mass.gov/masshealthpubs), click the MassHealth Provider Forms link in the Publications panel.

You can fax the completed form to: (617) 886-8133 or (617) 886-8134 OR mail the form to:

MassHealth Hospice Unit
UMMS-CHCF
529 Main Street
Charlestown, MA 02129

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

In accordance with newly established 5010 HIPAA transaction standards, all MassHealth claim submissions must include a valid diagnosis code, effective January 1, 2012. For the MassHealth vision care contractor (MassCor) to comply with these new HIPAA claim standards, VIS-1 order forms must now include a valid diagnosis code. The VIS-1 has been revised to reflect the new requirement.

To download a copy of the Vision Care Material Order Form (VIS-1) from the MassHealth Web site homepage (www.mass.gov/masshealth), click the MassHealth Provider Forms link in the Publications panel.

You can access the Vision Care Bulletin 16 (dated February 2012) from the online Provider Library (www.mass.gov/masshealthpubs) for more information about this change.

MassHealth recently implemented automated pricing for hospice services on claims submitted with Service Code T2046 (Hospice long term care, room and board only; per diem) for members receiving hospice services in a nursing facility. MassHealth’s claim processing system is now able to calculate the correct payment for the member’s casemix score and the nursing facility’s rate for that casemix score, multiplied by the number of units at 95 percent, less any applicable patient paid amount (PPA). Providers should continue to bill for services using Service Code T2046 as usual.

Please Note: MassHealth identified a defect that may have resulted in underpayments for claims processed with Service Code T2046 from 03/05/2012 through 03/07/2012. These claims will be systematically adjusted for correction. No further action is required by providers. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

MEDICARE CROSSOVER CLAIMS WITH MEDICARE COVERED AND NONCOVERED DAYS (MID-STAY) DURING AN INPATIENT STAY- for Acute Inpatient & Chronic Inpatient Hospitals

Medicare crossover claims for dually eligible members that contain both Medicare covered and noncovered days will be automatically transmitted from the coordination of benefits contractor (COBC) to MassHealth for processing. These crossover claims will suspend with edit 1803 (Recycle Medicare Part A claim). MassHealth will systematically collect the Medicare Part B ancillary payments associated with the inpatient stay, and will deduct the Medicare Part A and Part B payments from the final mid-stay crossover claim payment.

PLEASE NOTE: For all claims processed on or after 9/25/11, the payment for the Medicare covered and noncovered days is included in the MassHealth mid-stay crossover claim payment. Therefore, you should not bill MassHealth for the Medicare noncovered days.

If 60 days have passed since receipt of the Medicare payment, or the member has other insurance in addition to Medicare and MassHealth, and the claim has not appeared on a MassHealth crossover remittance advice, you may submit these claims to MassHealth electronically. Follow the MassHealth COB requirements in Appendix D (Supplemental Instructions for Claims with Other Insurance) of your MassHealth provider manual.

When billing Medicare inpatient mid-stay claims that contain Medicare covered and noncovered days for dually eligible members to MassHealth, providers should not report the Medicare Part B ancillary payments associated with the inpatient stay on their inpatient claim submission nor should they bill the Medicare noncovered days separately to MassHealth. The MassHealth payment for mid-stay claims includes the Medicare noncovered days and the Medicare Part B ancillary payments. Providers should follow instructions found in MassHealth billing guides for claims submissions.

MEDICARE CROSSOVER CLAIMS WITH MEDICARE COVERED AND NONCOVERED DAYS (MID-STAY) DURING AN INPATIENT STAY – for Psychiatric Inpatient & Semi-Acute Inpatient Hospitals

Medicare crossover claims for dually eligible members that contain both Medicare covered and noncovered days will be automatically transmitted from the coordination of benefits contractor (COBC) to MassHealth for processing.

PLEASE NOTE: For all claims processed on or after 9/25/11, the payment for the Medicare covered and noncovered days is included in the MassHealth mid-stay crossover claim payment. Therefore, you should not bill MassHealth for the Medicare noncovered days.

If 60 days have passed since receipt of the Medicare payment, or the member has other insurance in addition to Medicare and MassHealth, and the claim has not appeared on a MassHealth crossover remittance advice, you may submit these claims to MassHealth electronically. Follow the MassHealth COB requirements in Appendix D (Supplemental Instructions for Claims with Other Insurance) of your MassHealth provider manual.

When billing Medicare inpatient mid-stay claims that contain Medicare covered and noncovered days for dually eligible members to MassHealth, providers should not report the Medicare Part B ancillary payments associated with the inpatient stay on their inpatient claim submission nor should they bill the Medicare noncovered days separately to MassHealth. Providers should follow instructions found in MassHealth billing guides for claims submissions.

MassHealth has revised its claim submission procedures. Effective January 1, 2012, all claims must be submitted electronically. Only providers with an approved Electronic Claim Waiver Request form may submit paper claims. To download a copy of the Electronic Claim Waiver Request from the MassHealth Web site (www.mass.gov/masshealth), click the MassHealth Provider Forms link located in the Publications panel.

You must submit claims that require attachments and delay reason codes using DDE.

Claims that should be submitted with delay reason codes through DDE include:

90-Day Waivers (Please Note: The only delay reason codes for 90-Day Waivers are):

-1 (Proof of eligibility unknown or unavailable)

-4 (Delay in certifying provider)

-8 (Delay in eligibility determination)

For questions or instructions about accompanying documentation requirements for submission of these claims, refer to All Provider Bulletin 220, dated December 2011.

Final Deadline Appeals (Please Note: The only delay reason code for final deadline appeals is):

-9 (Original claim rejected or denied due to a reason unrelated to the billing limitation rules)

For questions or instructions about accompanying documentation requirements for submission of these claims, refer to All Provider Bulletin 221, dated December 2011.

National Correct Coding Issue (NCCI)/Medically Unlikely Edits (MUE) Appeal Requests and Certain Claims that Require Special Consideration (Please Note: The only delay reason code for this circumstance is):

-11 (Other)

Refer to message texts on your remittance advices (RA).

MassHealth communicates these messages weekly. You can access archived RA message texts as well as former bulletins from the online Provider Library at www.mass.gov/masshealthpubs. 

An incorrect delay reason code may delay the processing of your claim. 

You can obtain instructions on submitting DDE claims from the POSC job aids. From the MassHealth Web site (www.mass.gov/masshealth), select the Information for MassHealth Providers link. Click MassHealth Provider Trainings, then click NewMMIS Provider Training.

Please contact MassHealth Customer Service at providersupport@mahealthnet or 1-800-841-2900, if you need assistance with the POSC.

MassHealth has revised its claim submission procedures. Effective January 1, 2012, all claims must be submitted electronically. Only providers with an approved Electronic Claim Waiver Request form may submit paper claims. To download a copy of the Electronic Claim Waiver Request from the MassHealth Web site (www.mass.gov/masshealth), click the MassHealth Provider Forms link located in the Publications panel.

Providers must submit claims that denied for edit 2614 (Manage care service should be paid by MassHealth behavioral health) electronically via direct data entry (DDE) with delay reason code 11 (Other).

Providers must include scanned copies of the cover letter, medical records, and the remittance advice (RA) showing the 2614 denial, with the DDE claim submission. Please be sure to use the “Attachment” tab to upload the documents.

These claims will appear in a suspense status on your RA with edit 829 (NCCI appeal/special handle under review), while under review. Decisions will be reflected when your reprocessed claim appears on a future RA.

You can obtain instructions on submitting DDE claims from the POSC job aids. From the MassHealth Web site (www.mass.gov/masshealth), select the Information for MassHealth Providers link. Click MassHealth Provider Trainings, then click NewMMIS Provider Training.

Please contact MassHealth Customer Service at providersupport@mahealthnet or 1-800-841-2900 if you need assistance with the POSC.

MassHealth has revised its claim submission procedures. Effective January 1, 2012, all claims must be submitted electronically. Only providers with an approved Electronic Claim Waiver Request form may submit paper claims. To download a copy of the Electronic Claim Waiver Request from the MassHealth Web site (www.mass.gov/masshealth), click the MassHealth Provider Forms link located in the Publications panel.

Please remember to submit claims reviewed by Permedion Health Management Systems (HMS), electronically via direct data entry (DDE) using delay reason code 11 (Other).

Instances of when to use delay reason code 11 for such claim submissions include:

-claims that were denied inpatient admission by Permedion HMS and the claims are allowed to be billed as outpatient.

-Outpatient claims when Permedion HMS denied some claim lines (resubmit claims, omitting the denied lines);

-Inpatient claims that were billed incorrectly when Permedion HMS instructs the provider to correct and resubmit the claim; or

-Permedion HMS initially denied the inpatient claim but overturned the denial following a subsequent review and instructed the provider to submit a new claim.

To resubmit claims from the above instances when instructed by Permedion HMS, you must scan and submit the letter from Permedion HMS and any other supporting documentation to support your request for review. If you are submitting multiple claims for the same member, submit each DDE claim separately along with the scanned letter from Permedion HMS and other supporting documentation. Please be sure to use the “Attachment” tab to upload the documents.

These claims will appear on your remittance advice (RA) in a suspense status with edit 829 (NCCI appeal/special handle under review), while under review. Decisions will be reflected when your claim appears on a future RA.

Please contact MassHealth Customer Service at providersupport@mahealthnet or 1-800-841-2900 if you need assistance with the POSC.

As previously noted in remittance advice RA 100143 (dated 2/21/12), MassHealth identified an issue that caused claims for anesthesia services submitted between January 1, 2012 and February 13, 2012, with dates of service (DOS) between 7/1/2011 and 12/31/2011, to overpay. Providers were advised to refrain from submitting any adjustments to these claims while a modification was made to correct the issue so that impacted claims could be correctly reprocessed by MassHealth.

The reprocessed claims will begin appearing on RA 100145 (dated 3/6/12). If necessary, you may submit adjustments for claims affected by this issue. Please reference the most recent ICN on your adjustment. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

The HHABN is required by Section 1879 of the Social Security Act whenever a home health provider believes that the services to be delivered are not covered by Medicare. The home health provider must issue the HHABN for the services believed to be non-covered before initiation of those services, when there is a reduction in services, and at the termination of services. The HHABN is used to advise, or give legal notice to home health patients, who were either receiving Medicare or are eligible to receive Medicare that services delivered are not covered services.

All MassHealth home health providers must comply with MassHealth third party liability (TPL) regulations at 130 CMR 450.316 through 450.318. If a home health agency does not exercise diligent efforts, as defined at 130 CMR 450.316 (A), as making every effort to identify and obtain payment from all other liable third parties, including insurers, MassHealth may subject the provider to sanctions and recover any overpayments paid to the provider (See 130 CMR 450.316(C). Examples of failure to exercise diligent efforts are located at 130 CMR 450.316 (B) and include noncompliance with the billing and authorization requirements of the insurer. You can view MassHealth regulations from the Publications panel of the MassHealth Web site (www.mass.gov/masshealth).

PLEASE NOTE: To ensure that home health providers are using the HHABH as required by Medicare and are in compliance with MassHealth TPL regulations 130 CMR 450.316 through 450.318, MassHealth will be reviewing provider practices as part of the TPL review criteria in the issuance of the HHABN for episodes beginning on and after January 1, 2011, and may sanction and recover any overpayments paid to the provider that are out of compliance with Medicare HHABN or other billing requirements.

Effective January 1, 2012, MassHealth implemented changes to meet the Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 5010 federal requirements. As of January 1, 2012, MassHealth only accepts electronic transactions in the new HIPAA mandated 5010 format.

Please be sure to submit the relevant 5010 data elements when submitting 5010 transactions in production to avoid unnecessary denials. It is a good practice to validate receipt of a 999 file acknowledgement following any batch file submissions to MassHealth. A 999A file acknowledgement means that your file has been received successfully by MassHealth. A 999R file acknowledgement means your file was received but not processed. The ISA of your file provides confirmation that you submitted your file correctly. Please refer to the MassHealth Companion Guide for instruction about electronic claims submissions, and other useful information that can help you perform many online claim submission functions to MassHealth. You can access the Companion Guide from the 5010 Web site at www.mass.gov/masshealth/5010.

If you are seeking additional assistance or training on how to use MassHealth’s Provider Online Service Center (POSC) claims functionality to better understand the HIPAA changes and how they may impact you (to include testing and production file submission issues), contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

Providers with national provider identifier (NPIs) are required to include them on all claims (including those billing for Medicare services). If you are a provider with one NPI that corresponds to multiple MassHealth Provider ID/Service Location (PID/SL) numbers, it is important that you submit your claims to Medicare using the full 9-digit U.S. Postal Service’s ZIP code. A Medicare system issue is causing claims that do not include the 4-digit ZIP code extension to default to “9998” in this field, resulting in a discrepancy between the claim data and the MassHealth provider ID information on file. This discrepancy is causing claims to be denied with Edit 1945 (Mult sak prov locs for billing prov spec). It is important that you report your full 9-digit ZIP code to both Medicare and MassHealth as soon as possible to ensure proper claim adjudication. This is a requirement for 5010 claim submissions and was communicated in Provider Bulletin 208, dated February 2011 (MassHealth 5010 Key Concepts).

If you submitted a claim after January, 1, 2012 that denied with this NPI error (edit 1945), you must resubmit it to MassHealth with the corrected full 9-digit ZIP. If you have not reported your full 9-digit ZIP code to MassHealth, you can update this information via the Provider Online Service Center (POSC). Log onto the POSC from the MassHealth Web site (www.mass.gov/masshealth). From the POSC homepage, select the Manage Provider Information link, click Service Locations, and then add or update your doing business as (DBA) ZIP code. You can also update this information by completing a Change of Address form and faxing it to the number indicated on the form. You can download a copy of the form from the MassHealth Web site by clicking the MassHealth Provider Forms link in the Publications panel. Please allow two business days after MassHealth receipt of a change request before resubmitting your corrected claims.

To determine the 4-digit extension to your standard ZIP code, refer to the U.S. Postal Service’s ZIP Code Lookup tool, which can be accessed at http://tools.usps.com/go/ZipLookupAction!input.action.

MassHealth urges you to work with your software vendors to ensure that they capture the full nine digits for all billing provider and service facility addresses. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

TPL RESOURCE REMINDER

The MassHealth Web site contains billing guides, instructions and job aids to assist providers in submitting claims to MassHealth. Refer to the MassHealth billing instructions described in the MassHealth billing guides and companion guides (www.mass.gov/masshealth/5010) when submitting claims to MassHealth. These documents also contain specific instructions for submitting coordination of benefits (COB) claims.

POSC direct data entry (DDE) job aids are also available to instruct providers on how to submit institutional and professional COB claims. To access the COB claim submission job aids, go to www.mass.gov/masshealth. Select the Information for MassHealth Providers link and click New Medicaid Management Information System (NewMMIS and the Provider Online Service Center (POSC). Click Using the POSC for the First Time, and then click Get Trained. Refer to the Third Party Liability (TPL) heading.

The provider types listed below should refer to the appropriate appendix of their MassHealth provider manual for TPL exception instructions that may be applicable to their claim submissions. Please Note: The TPL appendices supplement instructions contained in the HIPAA implementation guides, MassHealth billing guides, and MassHealth companion guides.

- Acute Inpatient Hospitals (Appendix D)
- Chronic Disease and Rehabilitation Inpatient Hospitals (Appendix D)
- Community Health Centers (Appendix D)
- Home Health Agencies (Appendix D)
- Mental Health Centers (Appendix D)
- Nursing Facilities (Appendix G)
- Psychiatric Inpatient Hospitals (Appendix D)

The MassHealth provider manuals are located on the online provider library at www.mass.gov/masshealthpubs. 

Date

Title

Comments

You must attach a copy of your Notice of Denial from Permedion to every claim you rebill to MassHealth. Permedion conducts MassHealth’s Acute Hospital Utilization Management program. The rebilled claim and notice should be submitted to MassHealth using direct data entry (DDE). MassHealth will not accept a paper rebilling, unless the hospital has an approved waiver to submit paper claims. All rebilled claims must be submitted to MassHealth within the timeframe designated in your Notice of Denial from Permedion.

For example, if a claim for an inpatient admission (with dates of service from 4/1/12 through 4/2/12) has been denied and the hospital is rebilling for two days of outpatient services, then the hospital must submit a copy of the denial notice from Permedion for the outpatient services for EACH date of service being rebilled.

For more information about the rebilling process, refer to regulations at 130 CMR 415.414(B)(3). You can access MassHealth regulations from the Publications panel on the MassHealth Web site at www.mass.gov/masshealth. If you have questions, please contact Permedion at 617-398-1407.

When an outpatient service (claim line) has been denied by Permedion, MassHealth’s Acute Hospital Utilization Management contractor, the ENTIRE claim is also voided. To receive payment for the service(s) that were not denied, the hospital must submit a new claim, without the claim lines for the denied service(s), and attach a copy of the Notice of Denial from Permedion. The rebilled claim and notice should be submitted to MassHealth using direct data entry (DDE). MassHealth will not accept a paper rebilling, unless the hospital has an approved waiver to submit paper claims. All rebilled claims must be submitted to MassHealth within the timeframe designated in your Notice of Denial from Permedion. If you have questions, please contact Permedion at 617-398-1407.

To conform to the National Correct Coding Initiative (NCCI) methodology from the Centers for Medicare and Medicaid Services (CMS), MassHealth began enforcing new NCCI editing guidelines as described in All Provider Bulletin 209 (dated April 2011).MassHealth completed the system implementation for the coding updates at the end of October 2011. This change resulted in certain claims being incorrectly processed between 4/1/2011 and 10/31/2011. MassHealth is reprocessing the affected claims that contained NCCI procedure codes with dates of service between 10/1/2010 and 10/31/2011. The reprocessed claims will begin to appear on this or future remittance advices. If you have questions, please contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

Pharmacy providers should continue to follow the final deadline appeals process described in Appendix A of the MassHealth Pharmacy Online Processing System (POPS) Billing Guide (www.mass.gov/eohhs/docs/masshealth/pharmacy/pops-billing-guide.pdf).

Please Note: Pharmacy providers billing for durable medical equipment (DME) services using a CMS-1500 claim form should submit final deadline appeals through direct data entry (DDE) via the Provider Online Service Center (POSC) using delay reason code 9. For information and instructions about this process, refer to instructions in All Provider Bulletin 221 (dated December 2011). You can access MassHealth publications from the online Provider Library at www.mass.gov/masshealthpubs.

To check the status of a pending appeal, e-mail your inquiry to FDEAppeals@state.ma.us or call 617-847-3115. 

If you have questions about POPS billing and claims, you can contact the Xerox Technical Help Desk at 1-866-246-8503, 24 hours a day, seven days a week.

MassHealth has identified a system issue that may have resulted in underpayments for claims processed with service code T2046 from 3/5/12 through 3/7/12. The affected claims are being systematically adjusted and should begin appearing on remittance advice 100158 (dated 6/5/12). No further action is required by providers. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

This remittance advice may contain claims that were previously processed and denied at the header with at least one detail denied for edit 5010 (Exact duplicate – outpatient claim). The affected claims, with dates of service from 10/01/09 through 09/30/10, were denied because there were no HCPCS codes included on the line(s) with edit 5010.

For those paid claims with multiple lines, containing lines denied with edit 5010, MassHealth encourages providers to resubmit for consideration ONLY those lines that were denied for edit 5010 AND that contained no HCPCS codes. MassHealth suggests that you resubmit just those high charge lines that would move an episode to outlier in the payment amount per episode (PAPE) calculation. You must send any qualifying claims on a disc to the attention of Lydia Hatch at MassHealth, 100 Hancock Street, 6th Floor, Quincy, MA 02171. Discs must be received by 5/11/12 for consideration.

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

For providers with one national provider identifier (NPI) corresponding to multiple MassHealth Provider ID/Service Locations (PID/SLs), MassHealth uses the doing business as (DBA) address provided on the claim that corresponds to the unique service location to define where services were provided. When correcting paid claims, changing information such as the DBA or provider ID on your claim, will cause the replacement claim to adjudicate to a different service location from the one initially billed and will result in the claim being denied.

If more than 90 days have passed since the oldest date of service on the claim, and you want to change the DBA address, member ID, provider ID or claim type, please refer to the 90-day waiver procedures found in your MassHealth provider manual. You can access your MassHealth provider manual from the online Provider Library at www.mass.gov/masshealthpubs.

MassHealth has identified an issue that resulted in certain outpatient claims for lab services that were submitted with service codes G0431 and G0434 to be bundled into the payment amount per episode (PAPE) when they should have been processed according to the lab fee schedule. The affected claims were submitted with dates of service from 12/1/11 to 4/2/12. MassHealth is reprocessing these claims and the adjustments will begin to appear on this and future remittance advices.

Please Note: Claims that were submitted and paid a PAPE during this time frame will now show the PAPE portion of the payment taken back and the lab fee amount paid. If you have questions, please contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

MassHealthhas adjusted FQHC crossover claims with dates of service from 5/26/2009 to 8/29/2011 that were underpaid. The affected claims should begin appearing on this and future remittance advices (RAs). If the visit has been paid on both the institutional and professional claim, then informational Explanation of Benefits (EOB) code 5097 (Same service on professional crossover will be voided) will appear on the RA with the adjusted institutional crossover claim. Providers will be notified when the adjustment of these professional crossover claims has been processed.

Please Note: FQHC institutional crossover claims processed on or after 8/30/2011 have been paid correctly. Providers should continue to check Broadcast Messages and future RAs for updated information about the processing of these FQHC claims. If you have questions, please contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

MassHealth has identified an issue that caused some outpatient and medical claims to be denied erroneously with Edit 4801 (Procedure not covered by provider contract). MassHealth has resolved the issue and is reprocessing the affected claims. The reprocessed claims will appear on this or future remittance advices. No further action is required by providers. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

A suspended claim appears on a remittance advice (RA) for information only and requires NO action by a provider. Please do not correct or rebill a suspended claim.

Claims appear in a “SUSPEND” status for many reasons. The most common is that the claim must be manually reviewed by MassHealth to determine the appropriate fee, or the medical necessity of the service. Claims also suspend to allow time for the member eligibility or other files to be updated.

The majority of claims that suspend are adjudicated within 45 days of the suspense date.
Rebilling a claim already in suspense will only cause the subsequent claim submission to suspend as well.

You can track the status of a suspended claim using your internal control number (ICN), which can be found on your RA. To verify the status of a claim submitted to MassHealth for services provided to MassHealth members, you can use either batch HIPAA transaction sets 276/277 or the direct data entry (DDE) panel on the Provider Online Service Center (POSC).

Once the claim has adjudicated, it will appear on a subsequent RA as either “PAID” or “DENIED.” You should contact MassHealth Customer Service (1-800-841-2900) for assistance with your suspended claim only if your claim does not appear on your RA as adjudicated within 45 days of the suspension notice.

A suspended claim appears on a remittance advice (RA) for information only and requires NO action by a provider. Please do not correct or rebill a suspended claim.

Claims appear in a “SUSPEND” status for many reasons. The most common is that the claim must be manually reviewed by MassHealth to determine the appropriate fee, or the medical necessity of the service. Claims also suspend to allow time for the member eligibility or other files to be updated.

The majority of claims that suspend are adjudicated within 60 days of the suspense date.
Rebilling a claim already in suspense will only cause the subsequent claim submission to suspend as well.

You can track the status of a suspended claim using your internal control number (ICN), which can be found on your RA. To verify the status of a claim submitted to MassHealth for services provided to MassHealth members, you can use either batch HIPAA transaction sets 276/277 or the direct data entry (DDE) panel on the Provider Online Service Center (POSC).

Once the claim has adjudicated, it will appear on a subsequent RA as either “PAID” or “DENIED.” You should contact MassHealth Customer Service (1-800-841-2900) for assistance with your suspended claim only if your claim does not appear on your RA as adjudicated within 60 days of the suspension notice.

In accordance with newly established 5010 HIPAA transaction standards, all MassHealth claim submissions must include a valid diagnosis code, effective January 1, 2012. For the MassHealth vision care contractor (MassCor) to comply with these new HIPAA claim standards, VIS-1 order forms must now include a valid diagnosis code. The VIS-1 has been revised to reflect the new requirement.

To download a copy of the Vision Care Material Order Form (VIS-1) from the MassHealth Web site homepage (www.mass.gov/masshealth), click the MassHealth Provider Forms link in the Publications panel.

You can access the Vision Care Bulletin 16 (dated February 2012) from the online Provider Library (www.mass.gov/masshealthpubs) for more information about this change.

MassHealth recently implemented automated pricing for hospice services on claims submitted with Service Code T2046 (Hospice long term care, room and board only; per diem) for members receiving hospice services in a nursing facility. MassHealth’s claim processing system is now able to calculate the correct payment for the member’s casemix score and the nursing facility’s rate for that casemix score, multiplied by the number of units at 95 percent, less any applicable patient paid amount (PPA). Providers should continue to bill for services using Service Code T2046 as usual.

Please Note: MassHealth identified a defect that may have resulted in underpayments for claims processed with Service Code T2046 from 03/05/2012 through 03/07/2012. These claims will be systematically adjusted for correction. No further action is required by providers. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Medicare crossover claims for dually eligible members that contain both Medicare covered and noncovered days will be automatically transmitted from the coordination of benefits contractor (COBC) to MassHealth for processing. These crossover claims will suspend with edit 1803 (Recycle Medicare Part A claim). MassHealth will systematically collect the Medicare Part B ancillary payments associated with the inpatient stay, and will deduct the Medicare Part A and Part B payments from the final mid-stay crossover claim payment.

PLEASE NOTE: For all claims processed on or after 9/25/11, the payment for the Medicare covered and noncovered days is included in the MassHealth mid-stay crossover claim payment. Therefore, you should not bill MassHealth for the Medicare noncovered days.

If 60 days have passed since receipt of the Medicare payment, or the member has other insurance in addition to Medicare and MassHealth, and the claim has not appeared on a MassHealth crossover remittance advice, you may submit these claims to MassHealth electronically. Follow the MassHealth COB requirements in Appendix D (Supplemental Instructions for Claims with Other Insurance) of your MassHealth provider manual.

When billing Medicare inpatient mid-stay claims that contain Medicare covered and noncovered days for dually eligible members to MassHealth, providers should not report the Medicare Part B ancillary payments associated with the inpatient stay on their inpatient claim submission nor should they bill the Medicare noncovered days separately to MassHealth. The MassHealth payment for mid-stay claims includes the Medicare noncovered days and the Medicare Part B ancillary payments. Providers should follow instructions found in MassHealth billing guides for claims submissions.

MEDICARE CROSSOVER CLAIMS WITH MEDICARE COVERED AND NONCOVERED DAYS (MID-STAY) DURING AN INPATIENT STAY – for Psychiatric Inpatient & Semi-Acute Inpatient Hospitals

Medicare crossover claims for dually eligible members that contain both Medicare covered and noncovered days will be automatically transmitted from the coordination of benefits contractor (COBC) to MassHealth for processing.

PLEASE NOTE: For all claims processed on or after 9/25/11, the payment for the Medicare covered and noncovered days is included in the MassHealth mid-stay crossover claim payment. Therefore, you should not bill MassHealth for the Medicare noncovered days.

If 60 days have passed since receipt of the Medicare payment, or the member has other insurance in addition to Medicare and MassHealth, and the claim has not appeared on a MassHealth crossover remittance advice, you may submit these claims to MassHealth electronically. Follow the MassHealth COB requirements in Appendix D (Supplemental Instructions for Claims with Other Insurance) of your MassHealth provider manual.

When billing Medicare inpatient mid-stay claims that contain Medicare covered and noncovered days for dually eligible members to MassHealth, providers should not report the Medicare Part B ancillary payments associated with the inpatient stay on their inpatient claim submission nor should they bill the Medicare noncovered days separately to MassHealth. Providers should follow instructions found in MassHealth billing guides for claims submissions.

As previously noted in remittance advice RA 100143 (dated 2/21/12), MassHealth identified an issue that caused claims for anesthesia services submitted between January 1, 2012 and February 13, 2012, with dates of service (DOS) between 7/1/2011 and 12/31/2011, to overpay. Providers were advised to refrain from submitting any adjustments to these claims while a modification was made to correct the issue so that impacted claims could be correctly reprocessed by MassHealth.

The reprocessed claims will begin appearing on RA 100145 (dated 3/6/12). If necessary, you may submit adjustments for claims affected by this issue. Please reference the most recent ICN on your adjustment. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

The HHABN is required by Section 1879 of the Social Security Act whenever a home health provider believes that the services to be delivered are not covered by Medicare. The home health provider must issue the HHABN for the services believed to be non-covered before initiation of those services, when there is a reduction in services, and at the termination of services. The HHABN is used to advise, or give legal notice to home health patients, who were either receiving Medicare or are eligible to receive Medicare that services delivered are not covered services.

All MassHealth home health providers must comply with MassHealth third party liability (TPL) regulations at 130 CMR 450.316 through 450.318. If a home health agency does not exercise diligent efforts, as defined at 130 CMR 450.316 (A), as making every effort to identify and obtain payment from all other liable third parties, including insurers, MassHealth may subject the provider to sanctions and recover any overpayments paid to the provider (See 130 CMR 450.316(C). Examples of failure to exercise diligent efforts are located at 130 CMR 450.316 (B) and include noncompliance with the billing and authorization requirements of the insurer. You can view MassHealth regulations from the Publications panel of the MassHealth Web site (www.mass.gov/masshealth).

PLEASE NOTE: To ensure that home health providers are using the HHABH as required by Medicare and are in compliance with MassHealth TPL regulations 130 CMR 450.316 through 450.318, MassHealth will be reviewing provider practices as part of the TPL review criteria in the issuance of the HHABN for episodes beginning on and after January 1, 2011, and may sanction and recover any overpayments paid to the provider that are out of compliance with Medicare HHABN or other billing requirements.

Providers with national provider identifier (NPIs) are required to include them on all claims (including those billing for Medicare services). If you are a provider with one NPI that corresponds to multiple MassHealth Provider ID/Service Location (PID/SL) numbers, it is important that you submit your claims to Medicare using the full 9-digit U.S. Postal Service’s ZIP code. A Medicare system issue is causing claims that do not include the 4-digit ZIP code extension to default to “9998” in this field, resulting in a discrepancy between the claim data and the MassHealth provider ID information on file. This discrepancy is causing claims to be denied with Edit 1945 (Mult sak prov locs for billing prov spec). It is important that you report your full 9-digit ZIP code to both Medicare and MassHealth as soon as possible to ensure proper claim adjudication. This is a requirement for 5010 claim submissions and was communicated in Provider Bulletin 208, dated February 2011 (MassHealth 5010 Key Concepts).

If you submitted a claim after January, 1, 2012 that denied with this NPI error (edit 1945), you must resubmit it to MassHealth with the corrected full 9-digit ZIP. If you have not reported your full 9-digit ZIP code to MassHealth, you can update this information via the Provider Online Service Center (POSC). Log onto the POSC from the MassHealth Web site (www.mass.gov/masshealth). From the POSC homepage, select the Manage Provider Information link, click Service Locations, and then add or update your doing business as (DBA) ZIP code. You can also update this information by completing a Change of Address form and faxing it to the number indicated on the form. You can download a copy of the form from the MassHealth Web site by clicking the MassHealth Provider Forms link in the Publications panel. Please allow two business days after MassHealth receipt of a change request before resubmitting your corrected claims.

To determine the 4-digit extension to your standard ZIP code, refer to the U.S. Postal Service’s ZIP Code Lookup tool, which can be accessed at http://tools.usps.com/go/ZipLookupAction!input.action.

MassHealth urges you to work with your software vendors to ensure that they capture the full nine digits for all billing provider and service facility addresses. If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

MENTAL HEALTH CENTER (MHC) AND COMMUNITY HEALTH CENTER (CHC) THIRD PARTY LIABILITY (TPL) INSURANCE BILLING REMINDER

To ensure that MassHealth is the payer of last resort, MHC and CHC providers must generally make diligent efforts to obtain payment from other resources prior to billing MassHealth (see MassHealth All Provider  regulations at 130 CMR 450.316). Providers may submit coordination of benefits (COB) claims with a remaining patient responsibility to MassHealth by following instructions found in the HIPAA 837 implementation guides (www.wpc-edi.com) and the MassHealth companion guides (www.mass.gov/masshealth/5010) and provider specific appendices, where applicable. 

For services rendered by a clinician who is not certified by Medicare, MHC and CHC providers may submit claims directly to MassHealth using the “Total Non-Covered Amount” field as instructed in Appendix D of your MassHealth provider manual. You can access the provider manuals from the online provider library at www.mass.gov/masshealthpubs. MHC and CHC providers are authorized to use this field only to submit claims for services rendered by a Medicare non-certified clinician. Services that are denied by other insurers should be billed to MassHealth using the applicable HIPAA adjustment reason code(s).

TPL RESOURCE REMINDER

The MassHealth Web site contains billing guides, instructions and job aids to assist providers in submitting claims to MassHealth. Refer to the MassHealth billing instructions described in the MassHealth billing guides and companion guides (www.mass.gov/masshealth/5010) when submitting claims to MassHealth. These documents also contain specific instructions for submitting coordination of benefits (COB) claims.

POSC direct data entry (DDE) job aids are also available to instruct providers on how to submit institutional and professional COB claims. To access the COB claim submission job aids, go to www.mass.gov/masshealth. Select the Information for MassHealth Providers link and click New Medicaid Management Information System (NewMMIS and the Provider Online Service Center (POSC). Click Using the POSC for the First Time, and then click Get Trained. Refer to the Third Party Liability (TPL) heading.

The provider types listed below should refer to the appropriate appendix of their MassHealth provider manual for TPL exception instructions that may be applicable to their claim submissions. Please Note: The TPL appendices supplement instructions contained in the HIPAA implementation guides, MassHealth billing guides, and MassHealth companion guides.

- Acute Inpatient Hospitals (Appendix D)
- Chronic Disease and Rehabilitation Inpatient Hospitals (Appendix D)
- Community Health Centers (Appendix D)
- Home Health Agencies (Appendix D)
- Mental Health Centers (Appendix D)
- Nursing Facilities (Appendix G)
- Psychiatric Inpatient Hospitals (Appendix D)

The MassHealth provider manuals are located on the online provider library at www.mass.gov/masshealthpubs. 

Authorized provider types will use a new data element “Total Noncovered Amount” to report noncovered charges on HIPAA 5010 claims, for specific TPL exception conditions described in your MassHealth provider manual TPL appendix. Providers who are authorized to use a “Total Noncovered Amount” when reporting specific TPL exception conditions are listed below, with their related TPL appendix noted in parentheses:

- Acute Inpatient Hospitals (Appendix D)
- Chronic Disease and Rehabilitation Inpatient Hospitals (Appendix D)
- Community Health Centers (Appendix D)
- Home Health Agencies (Appendix D)
- Mental Health Centers (Appendix D)
- Nursing Facilities (Appendix G)
- Psychiatric Inpatient Hospitals (Appendix D)

The exception instructions are located in the Supplemental Instructions for Claims with Other Insurance in theAppendix section of each provider manual as noted. You can access the provider manuals from the online provider library at www.mass.gov/masshealthpubs.

Provider manual TPL appendices contain specific MassHealth billing instructions for members who have Medicare or commercial insurance. The TPL appendices supplement instructions contained in the HIPAA Implementation Guides and MassHealth Companion Guides and Billing Guides. Providers who are not authorized to use the new 5010 field “Total Noncovered Amount” should report the HIPAA adjustment reason code provided by the other insurer on their MassHealth claim submission to indicate the other insurer has not paid the claim.

On 12/21/11 the Centers for Medicare and Medicaid Services (CMS) notified MassHealth that Medicare did not have the capability to complete conversion of HIPAA 4010A1 837 run out claims to HIPAA Version 5010 for some Coordination of Benefits Agreement (COBA) trading partners that implemented HIPAA Version 5010 on 1/1/12. The affected 4010A1 run out claims (both institutional and professional) were most likely received by Medicare between 12/16/11 and 12/23/11.

MassHealth communicated on several occasions that it would not process 4010A1 837 claim files received after 1/1/12. However, providers may submit their crossover claim directly to MassHealth for payment consideration if their 4010A1 run out claim was received by Medicare between 12/16/11 and 12/31/11 and there is a remaining MassHealth member liability on the claim. Affected claims should be submitted to MassHealth using 837 batch submissions or via the Provider Online Service Center (POSC) using direct data entry (DDE). If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

MassHealth requires providers to obtain prior authorization (PA) for certain services. Please review your MassHealth program regulations for a proposed service to determine when PA is required. Please note that PA reqMarch 26,uests for certain services require additional forms that must accompany the request. In addition to program regulations, PA requirements may appear in Subchapter 6 of certain provider manuals, in provider bulletins, or in other written issuances from MassHealth. You can access the MassHealth provider manuals and provider bulletins from the MassHealth online Provider Library at www.mass.gov/masshealthpubs.

MassHealth reviews PA requests on the basis of medical necessity only and does not establish or waive any other prerequisites for payment, including eligibility or referral. Please remember to request a new PA for any subsequent request for the same service. The approval of a PA is not a guarantee of payment. You must still verify the member’s eligibility, other insurance, and any other restrictions before providing service. 

MassHealth strongly encourages all providers to request PA using the Provider Online Service Center (POSC) at www.mass.gov/masshealth/providerservicecenter. Providers can submit PA requests, all attachments (including supplemental and paper PA forms), and any subsequent PA requests, as well as review the status of their PA requests, electronically via the POSC. 

MassHealth has noticed an increase in the number of claims being submitted with incomplete or erroneous PA information. Some of the common denials being reported are listed below, followed by suggested resolution tips. Please make every effort to follow these PA guidelines to avoid claim issues.

• Edit code 3003 (Procedure code requires PA): Refer to Subchapter 6 of your provider manual and review the Benefit Administration section of the REFERENCE tab for PA restrictions.
• Edit code 3009 (PA number not on the database): Please ensure that your PA number listed is complete and/or correct. (The PA number can be Claims and Payments
• found on the claim header.)