Q.  What is the MassHealth electronic-claim-submission policy?

A.  As of January 1, 2012, all claims submitted to MassHealth must be submitted electronically unless a provider has an approved electronic-claim waiver. The waiver guidelines are included on the waiver form or can be found in All Provider Bulletin 217.

Q.  What are my options for submitting claims electronically?

A.  There are two options for submitting claims electronically. From the Provider Online Service Center (POSC), you can submit 837 batch files or you can submit claims individually via direct data entry (DDE).

Q.  What if I am having difficulty submitting claims electronically?

A.  For assistance with submitting electronic claims please contact

MassHealth Customer Service

1-800-841-2900

Hours: Monday–Friday, 8:00 A.M.–5:00 P.M.

E-mail: providersupport@mahealth.net.

Q.  What if I am unable to submit claims electronically?

A.  If you are unable to submit claims electronically, you may be eligible for an electronic-claim waiver. Please refer to All Provider Bulletin 217 for more information.

Q.  Who is eligible for an electronic-claim waiver?

A.  Providers who meet certain criteria are eligible for an electronic-claim waiver. Waiver criteria are included on the waiver form. Download the form from www.mass.gov/masshealth or contact MassHealth Customer Service for the form. Return the signed and completed form to MassHealth via email, fax, or mail. Your form will be approved or denied within 30 days. For additional information, refer to All Provider Bulletin 217.

Q.  Does this policy apply to 90-day waivers and final deadline appeals?

A.  Optional. As of January 1, 2012, MassHealth will accept 90 Day Waivers and Final Deadline Appeals electronically through DDE. Before January 1, 2012, MassHealth did not accept these electronically.

Q.  Does this policy apply to TPL and crossover claims?

A.  Yes. TPL and crossover claims are subject to this policy. All TPL and crossover claims can be submitted using the HIPAA COB information via both 837 batch and DDE.

Q.  Does this policy apply to claims with attachments?

A.  Yes. Documents must be attached to claims submitted electronically through DDE.

Q.  Does this policy apply to paper-claim resubmissions, voids, and adjustments?

A.  Yes. For more information, refer to the MassHealth Paper Claim Resubmissions, Adjustments, and Voids guidelines, or contact MassHealth Customer Service.

Q.  Does this policy apply to dental claims?

A.  No. This policy does not apply to claims submitted on the American Dental Association (ADA) form.


MassHealth Paper-Claim Resubmissions, Adjustments, and Voids Guidelines

Resubmissions

Resubmit DDE

Resubmit 837

Additional Information

Paper claims denied less than 90 days from the date of serviceYesYesResubmit as a new claim. Enter all the information from the paper claim via DDE or 837 batch. No ICN necessary.
Paper claims denied more than 90 days from the date of service where provider ID, member ID, or claim type is not changingYesYesEnter all the information from the paper claim via DDE or 837 batch. Auto ICN lookup will be performed to confirm that claim was originally submitted on time.
Paper claims denied more than 90 days from the date of service when provider ID, member ID, or claim type is changingYes*NoThese claims may be submitted as a 90-day waiver via DDE. 
Enter all the information from the paper claim on the DDE transaction and use the applicable delay reason code and attach supporting documentation. *Available only after January 1, 2012, in accordance with HIPAA 5010.
Paper claims denied more than 90 days from the date of service when date of service, procedure code, revenue code, or modifier is changingYes*NoThese claims may be submitted as a 90-day waiver via DDE.
Enter all the information from the paper claim on the DDE transaction and use the applicable delay reason code and attach supporting documentation. *Available only after January 1, 2012, in accordance with HIPAA 5010.

Adjustments

Adjust DDE

Adjust 837

Additional Information

Paid paper claimsNoYesEnter all the information from the paper claim via 837 batch. Include the ICN of the original paid claim as the former ICN of the replacement claim—no auto lookup.
Denied paper claimsN/AN/ADenied claims cannot be adjusted.

Voids

Void DDE

Void 837

Additional Information

Paid paper claimsNoYesEnter all the information from the paper claim via 837 batch. Include the ICN of the original paid claim.
Denied paper claimsN/AN/ADenied claims cannot be voided.