MassHealth has compiled a list of questions and answers that deal with issues that some providers have encountered during their transition to NewMMIS. MassHealth hopes you will find this information useful as you continue to make system and processing changes. As always, please remember to check the NewMMIS Web page for updates at


NewMMIS System and Processing Frequently Asked Questions



Claim Submissions: Paper and Electronic


Q: My claims were denied before implementation, and I need to resubmit them. Can I resubmit them on the old proprietary claim form?

A: All paper claims and paper claim adjustments must be submitted on industry-standard CMS-1500 or UB-04 claim forms. Providers must use their NPI (national provider identifier). "Atypical providers" should bill using their 10-digit provider ID/service location number, which was sent to providers in the MassHealth provider PIN registration letter.

Note: To ease transitions, for a limited time, MassHealth is allowing providers to use seven-digit PCC referral numbers that were issued by the PCC before NewMMIS implementation with two leading zeros (so that they are now nine digits in length) and 10-digit member IDs used in the legacy system. Providers may also submit electronic claims using the legacy member ID, but not paper claims.


Q: Where can I get copies of the UB-04 or CMS-1500 claim forms?

A: MassHealth does not supply these forms. You should seek out either local or online office supply vendors or office supply stores to obtain supplies of these forms.


Q: Where should I enter my NewMMIS Provider ID SL number on the industry-standard paper claim forms?

A: Unless you are an "atypical provider" (see All Provider Bulletin 181 pdf format of all-181.pdf
), you should bill with your NPI only, and not enter your provider ID/service location (PID SL) anywhere on the form. "Atypical providers" should enter their PID SL in Field 33b on the CMS-1500 and Field 57A-C on the UB-04 form, using the instructions outlined in each guide.


Q: Where should I indicate adjustments and resubmittals on the paper claim forms?

A: On the CMS-1500, use Field 22, and on the UB-04, use Field 64A. Be sure to follow the instructions outlined in each billing guide. Refer to the CMS-1500 Billing Guide  pdf format of bg_cms-1500-paperclaims-draft.pdf
and the UB-04 Billing Guide  pdf format of bg-ub04-draft.pdf
file size 1MB for detailed instructions on completing paper claims. 


Q: Are the rules about when to submit adjustments and resubmittals in NewMMIS the same as when to submit them in the legacy system?

A: Yes. However, when adjusting or resubmitting a claim that was previously processed in the legacy system, you must enter an "A" or "R," as applicable for the transaction, and then add "20" in front of the former transaction control number (TCN) (so that it becomes a 12-digit number). When resubmitting a claim that was originally processed in NewMMIS, you must list the ICN, preceded by the respective "A" or "R" only.


Q: Where does the patient paid amount (PPA) go on the UB-04?

A: Enter the PPA in Fields 39 through 41, using the instructions outlined in the UB-04 Billing Guide  pdf format of bg-ub04-draft.pdf
file size 1MB .


Q: How do I distinguish between medical leaves of absence (MLOA) and nonmedical leaves of absence (NMLOAs) on the UB-04?

A:Use Revenue Code 0185 to indicate MLOA and Revenue Code 0183 to indicate NMLOA. Refer to the UB-04 Billing Guide  pdf format of bg-ub04-draft.pdf
file size 1MB for complete instructions.


Q: On the CMS-1500 form, does the PCC referral information go in Field 17 or 23?

A: Enter the referral number in Field 23 of the CMS-1500. Field 17 is used to capture the name of the referring provider and Field 17b captures the referring provider's NPI.


Q: For certified independent labs, is the CLIA number needed on the CMS-1500?



Q: When a nursing facility resident has a patient paid amount (PPA), the companion guide instructions say to use Value Code F5, but the UB-04 instructions say to use Value Code FC. Which is correct?

A: Both are correct for the specified type of claim. When billing on the UB-04 claim form, providers should use Value Code FC to indicate a PPA. When submitting an 837I transaction, providers should use F5 to indicate a PPA. Providers must be sure to use the appropriate codes based on the type of claim they are submitting.


Q: Why do my claims keep getting denied?

A: Make sure that you are billing according to the updated billing instructions at Below are a few examples of reasons that some claims may be denied for certain provider types, along with tips that should help you to avoid these situations.

  • Hospitals: Enter a four-digit type-of-bill code. Although type-of-bill codes have not changed, these codes should lead with a zero. Also, in Fields 39 through 41, list only Value Code 24 (per the UB-04 instructions) and the total charge. Do not use the Medicaid rate code. Value Code 80 must be listed in Fields 39 through 41 with covered days. In addition, providers must remember to use their NPI or their new provider ID when listing an attending physician on an institutional claim.
  • Long-Term-Care (LTC): Remember to check the UB-04 instructions for completing Fields 39 through 41 and for a complete list of all acceptable revenue codes. Providers are now required to list Value Code FC along with the patient paid amount (PPA) when the member has a PPA. Recently MassHealth has noticed an increase in denied claims for long-term-care facilities due to use of incorrect revenue codes.
  • Home Health Agencies/Hospice Providers: Adjustments for home health agencies and hospice providers with paid claims that had been submitted on MassHealth proprietary claim form no. 9 with a span of dates can be submitted with a span of dates in NewMMIS.
  • Changes of Ownership: In NewMMIS, new provider IDs are issued for providers experiencing a change of ownership or some other change that would have normally prompted the need for a new provider ID in the legacy system.


Q: I used to use Provider Claims Submission Software (PCSS), but now the system says it is not available. How should I submit my claims in NewMMIS?

A: May 15, 2009, was the last day to submit electronic claims to the Customer Web Portal using PCSS. Providers can now use the DDE option or bill on paper. You can also obtain software from the Approved Vendor List pdf format of vendor-listing.pdf
that will allow you to create and submit batch 837 files.


Q: How can I exit a tab in the DDE function so that I can continue in the system?

A: Remember to click on "cancel the item" if you clicked on a tab. This prompts the system to exit and allows you to continue. Do not select the command "cancel the service," or your entire transaction will be lost. It is important to note that you should click on "Add Item" to save your updates periodically when prompted by the system.


Q: Why can't I upload my claims through the site anymore?

A: HIPAA batch transactions must be submitted via the Provider Online Service Center (POSC) or system to system using the Healthcare Transaction Service (HTS).


Q: Will I be able to continue to receive my MassHealth supplemental RA in NewMMIS? Where will I go to download my 835?

A:Providers should log on to the POSC to download 835 responses. NewMMIS does not generate supplemental RAs.


Q: I am missing my 997 file. What can I do to locate it?

A: In general, 997 responses are issued within one hour of MassHealth's receipt of an 837 file. Recently, however, some providers have reported a delay in this process. Please allow 24 hours following the submission of your 837 file before calling MassHealth Customer Service to inquire about your 997 file. During that time you should check the following information.

  1. advised providers about the need to update their submitter field with the appropriate MassHealth ID as a preparation step for completing 837 transactions in NewMMIS.
  2. Confirm that 837 files are sent as production files, with a "P" entered into the ISA15 field. Files submitted with a "T" are processed as test files only. If all of the above information has been confirmed, the 837 file may have failed pre-compliance. Mistakes in completing the ISA06 field of the 837 file are among the most common submitter mistakes to cause a pre-compliance failure. The ISA06 is a fixed field. The submitter must enter exactly 15 characters and spaces into the field. Providers must enter their 10-digit provider ID/service location number followed by five spaces (that is, depress the space bar on your keyboard five times).

Please note that the MassHealth EDI team is tracking the submission of 837 files and, for a time, is contacting those providers with files that have failed pre-compliance to further assist in correcting the issue. For more information about the ISA06, ISA, and GS02 fields, refer to the HIPAA Implementation Guide.

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Q: Why can't I submit eligibility requests through WebREVS anymore?

A: The last day to use WebREVS and REVSpc was May 23, 2009. You must submit eligibility requests using the POSC or the updated EVSpc software.


Q: REVSpc is saying that I need an upgrade and will not let me complete my batch eligibility transaction.

A: You can obtain the updated software at Click on Need Additional Information or Training, then on Information and Software for Electronic Transactions, then on Download EVSpc software.


Q: Does the eligibility response show policy numbers for other insurance, in addition to the name of the other insurance?

A: Yes, if a member has other insurance in addition to MassHealth, the eligibility response shows the policy numbers and names for the other insurance.


Q: MassHealth has indicated that ZZ numbers are not going to be issued in NewMMIS. How will providers bill for a newborn in NewMMIS?

A: Providers should submit a notification of birth (NOB-1) form to MassHealth, which will trigger the issuance of a 12-digit MassHealth member ID. ZZ numbers will not be issued in NewMMIS. Providers will be able to verify eligibility and enrollment using their NewMMIS member ID, member's SSN, other agency ID (X or Y RID), or name.

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General POSC Questions


Q: What should I enter in a date field if I don't have a date to enter, and the system will not let me continue?

A: Use the default end date 12/31/2299 with no dashes, slashes, or spaces.


Q: Do I need to complete any fields that are not marked with a red asterisk?

A: The absence of an asterisk does not indicate that the field is not required. MassHealth designated with a red asterisk only certain fields that are consistently required in any given transaction. The remaining fields are conditionally required, depending on the transaction or the applicable function.

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Q: Will I still be able to use the current MassCOR forms in NewMMIS?

A: MassHealth has revised MassCOR's vision-care-material order form to accommodate the new 12-digit member ID numbers. The form is now fillable online. You can download the forms at .

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Q: How long will it take Masspro to respond to PAS requests entered through NewMMIS? Are there any specific guidelines to follow to shorten response time?

A: The turnaround time is dependent upon how much lead time providers give Masspro when they submit their requests. The regulations at 130 CMR 450.208(A) state that providers must give seven days' lead time, but in the majority of cases they do not. Masspro prioritizes submitted requests daily. Last-minute requests can affect Masspro's processing time. Please remember to submit PAS requests following the seven-day time frame to prevent system delays.

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PCC Plan and NewMMIS


Q: When searching for a servicing provider number in the referral section, should you assign the referral by an individual practitioner or by group?

A: It is up to the PCC provider how a referral is issued. The PCC can choose to issue a referral to a particular individual or to a group. However, as identified above, if the individual providing services is different from the individual or group to whom the referral is issued, then the specialist office should contact the PCC office for a new referral to reflect the provider who saw the PCC Plan member.


Q: Will all providers who are enrolled with MassHealth continue to be listed in the system and searchable?

A: Yes. Any provider who is active with MassHealth will remain searchable for referral purposes. In addition, the PCC provider will not be required to know the demographic details of that individual or group to issue a referral to them.


Q: Does the PCC need to list a service code when submitting a referral, or can the referral be sent without one?

A: The procedure code field is not a mandatory field for referrals. However, to simplify the process for the servicing provider, it would be helpful to use the "Notes" field with brief details on the purpose for issuing the referral.


Q: In the "Reason for Referral" field, there are three options: "Consult," "Consult and test," and "Consult, test, and treat." What does each of these mean and which option should I choose?

A: At times, the PCC may elect to send a patient for a consultation ("Consult") only. The "Consult and test" option allows for both consultation and diagnostic testing. The "Consult, test, and treat" referral allows the referred provider to treat in addition to consultation and testing. It is anticipated that the third choice will be the most frequently selected option.


Q: If a member changes his or her managed-care status (for example, changes PCCs), will the change become effective immediately for both the member and the PCC?

A: Yes. The change will be reflected immediately in the system.


Q: If I am providing a service based on a referral that was issued before NewMMIS implementation, will the new system automatically match up the legacy referral number with incoming claims or should I list the legacy authorization number on the claim?

A: The provider must list the legacy referral number on the claim. The system does not link a legacy referral number to the new claims processing system in NewMMIS. As a reminder, this seven-digit legacy number, per All Provider Bulletin 188 pdf format of all-188.pdf
, should be preceded with two leading zeros.


Q: Can providers use a 10-digit "dummy" number if they do not have a referral number?

A: No. There are no "dummy" numbers in NewMMIS for referrals. If there is no referral number indicated, the PCC should be contacted to request a referral for the member. Once referral terms are verified, the PCC office should submit a referral.


Q: I am trying to issue a referral for a member who was seen at one of our sites, but I keep getting a "Provider not a PCC or covering physician for the member" message. What should I do?

A: If the member is identified with a PCC, PCC providers have always issued referrals from the primary PCC site, even if that PCC had multiple sites from which the members could obtain services and the member was seen at one of the secondary sites. But in NewMMIS, each PCC site is assigned a separate NewMMIS provider ID/service location. The individual site to which the member is identified must now issue referrals for that member. The monthly PCC panel report from MassHealth identifies PCC member site assignment. In general, if the member is assigned to the group, the group must issue the referral. If the member is assigned to a specific site within a multi-site practice, then the specific site must issue the referral.


Q: A subordinate user from one of our secondary site offices is trying to issue a referral for one of their members, but keeps getting the following message: "Provider not a PCC or covering physician for the member." What should we do?

A: As part of the NewMMIS transition, MassHealth is linking secondary sites to primary sites under the same primary user. MassHealth mailed a PCC multi-site PID SL cover letter explaining the PCC linking process to providers' primary site Doing Business As addresses in the first week of June. However, as this letter indicated, it is your primary user's responsibility to assign subordinate access (as needed) to any secondary sites. In NewMMIS, referrals must be issued by the servicing secondary site to which a member is identified. If a subordinate user has not been linked (that is, given access) to the secondary site, that subordinate user will not be able to issue a referral to a member.


Q: I am a primary user at a PCC who has just registered in the POSC. I don't see my secondary sites registered on my account. How can I locate my secondary sites?

A: If you recently registered as a primary user with your primary-site provider ID, you may not have the capability to link those subordinate sites to your primary site. MassHealth is continuing to identify new registrants and will process the linking of all associated secondary sites to the primary user of the primary site in NewMMIS. Remember, however, that your primary user will still need to assign subordinate access to those secondary sites. If you are properly registered, you should be able to log into your primary provider POSC account and view your secondary (subordinate) sites listed in the drop-down menu.

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Referral Questions


Q: When do I need to issue a referral or obtain PA?

A: PCC providers must issue referrals when they want their PCC member to be seen or treated by a specialist or another provider. Some services may be provided by a MassHealth provider without a referral. The PCC will issue a referral when appropriate, in accordance with MassHealth regulations at 130 CMR 450.118 and All Provider Bulletin 188. If prior authorization (PA) is needed in addition to a referral, the servicing provider/specialist must obtain it as applicable to the services provided according to service codes listed in Subchapter 6 of your provider manual.


Q: What if a member enrolled in the PCC Plan is in my office without a referral? We sometimes get calls from members who have been turned away with no referral when they are not enrolled or not eligible to be enrolled in managed care.

A: If the service requires a referral (see All Provider Bulletin 188 pdf format of all-188.pdf
for a list of services that require a PCC referral), you should call the member's PCC and request a referral. If the service requires a referral and you are not able to get one, you should defer care until a referral is received. Your responsibility is to tell the member that he or she may not receive care until he or she meets the requirements of his or her health plan. This is not a violation of your contract, as no care is being denied; care is merely being deferred. If the member was referred to you for care before May 26, 2009, and you have a seven-digit referral number issued before NewMMIS implementation from the member's PCC, you can add two leading zeros to that seven-digit referral number and enter it on your claim.


Q: Can a referral be issued to a group, or are referrals issued to a specialist (individual practitioner) only?

A: Referrals may be issued to a group or to an individual practitioner. However, if a referral is issued to an individual who is part of a group the member must be seen by that individual. If not, then a new referral will be necessary to cover the service provided by another provider.


Q: If a PCC provider issues a referral for a consult only, but the specialist deems treatment necessary, should the PCC update the "Reason for Referral" field on the referral or should the PCC issue a second referral to the specialist?

A: The PCC will need to issue a new referral.


Q: If a referral was assigned to an individual and someone else in that practice actually provides services to the member, can the specialist's office change the referral to the appropriate practitioner?

A: The PCC's office, not the specialist's office, must create a new referral for the specialist who saw the PCC Plan member.


Q: What should be done if the member is being treated by a specialist's office for an emergency situation, and the member's PCC will not issue a referral?

A: Referrals are not required in emergency situations.


Q: A member has been seeing a doctor for primary care even though this doctor is not the member's assigned PCC, and the member wants to go to a specialist. The member needs a referral for the specialist visit, but the member's assigned PCC refuses to issue one. The member visits the specialist without the referral and subsequently changes PCC affiliation to that specialist. Can the new specialist issue a referral?

A: If the member has received a service that requires a PCC referral, and that service was provided by someone other than his or her PCC, the specialist will not be paid without a referral from the member's PCC. However, the member may change his or her PCC at any time and this change will be effective immediately. Generally speaking, specialists do not meet the criteria to participate in the PCC Plan as a PCC. If a specialist is board certified or board eligible for one of our primary care specialties-that is, internal medicine, family practice, OB/GYN, or pediatrics-the specialist may apply to become a PCC.


Q: Wouldn't it be easier for the provider to always issue a referral for more visits in advance for a particular member (that is, issue the referral for more visits to avoid having to issue a second referral or correcting the original referral if the member needs more visits)?

A: The conditions and terms of referral should remain at the discretion and medical opinion of the issuing PCC.


Q: Can a provider request a PCC referral for a certain amount of time (for example, for a one-year period)?

A: Referrals can be issued for the amount of time the PCC deems appropriate. For instance, a PCA referral could be for one year, longer, or shorter. The duration is entirely up to the PCC. If the servicing provider has compelling reasons for why a referral should be issued for a certain amount of time, the servicing provider can speak with the PCC to request that time span.


Q: Can a PCC referral be retroactive? And if so, how far back can it go?

A: Yes. A referral can be made as far back as the PCC deems is appropriate.

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Security Access


Q: How should providers use the Provider Online Service Center;(POSC)?

A: The POSC was designed to be a destination for providers. You should log into the system in the morning and keep it active throughout the day.


Q: I am having difficulty logging in to the POSC. The site seems to be unavailable at times and at other times I just get an error message or unrecognizable login message.

A: Please wait 15 minutes and try logging in again. Make sure that the difficulty is not occurring during scheduled system maintenance (usually at night or on weekends). You should check for broadcast messages on the POSC often for information about scheduled system maintenance. In addition to notifying providers through broadcast messages, MassHealth also posts important announcements and updates on the NewMMIS Web page. You can access any NewMMIS-related announcements directly at Providers should make every effort to take advantage of these resources to stay informed. If neither of these suggestions works, please contact the Virtual Gateway Help Desk at 1-800-421-0938.


Q: What are broadcast messages?

A: Broadcast messages are messages posted on the POSC that alert providers about critical system updates and other MassHealth-related information. Broadcast messages are ranked on a priority scale from 1 to 5 ("5" being the highest priority). Messages will remain on the POSC for an extended period of time so that providers have ample opportunity to read and revisit them as needed.

To access broadcast messages, log in to the POSC at , click on Manage Correspondence and Reporting, and then on View Broadcast Messages. MassHealth encourages you to view messages daily for timely updates.


Q: I do not appear to have POSC access. What should I do?

A: Check to make sure that your organization has received a PIN (personal identification number) letter and has registered for access to the POSC. Your primary user should have created a permanent password in the Virtual Gateway, using the information in the PIN letter and the temporary password received via e-mail after initial POSC registration.

If your organization has registered, please confer with your primary user to determine if that person has created an account for you to access the POSC. If you are a subordinate user, the primary user must create a subordinate ID in order for you to have access.

If your organization has not registered, please designate a primary user who will be responsible for coordinating POSC access for staff within your organization and follow the steps in the " "at Click on Using the POSC for the First Time, then on Register and Set Up Security Access for the POSC.

Be sure to follow the Virtual Gateway password security guidelines when creating a password. The password must be between eight and 16 characters with at least one capital letter and at least one number. To review the job aids, which offer additional information about NewMMIS tasks, go to, click on Get Trained, then scroll down to the applicable job aid. You can also try validating that you are using the correct link to access the POSC.


Q: My access to certain functions on the POSC appears to have been removed in error. What should I do?

A: Previously, a number of security defects had been identified. These issues have been resolved. If you experience a problem, please do not create additional IDs for users. This only contributes to the number of unused accounts. Please contact MassHealth Customer Service at 1-800-841-2900 if you continue to have problems.


Q:What should I do when I receive an error message that starts as "javax.portlet. PortletException: Cannot get value for expression"?

A: MassHealth previously identified this as a system issue and corrected the problem. If you receive this error message, log out of the system, wait 15 minutes, and log back in.


Q: I can't register for POSC access using my PIN and provider ID, because I do not remember receiving login information. What should I do?

A: Some providers have found that this information had been routed to their spam or junk e-mail folder. Check alternative sources as appropriate to see if this information was inadvertently misrouted to such a folder. If you still cannot locate the user name and password information, please contact MassHealth Customer Service at 1-800-841-2900.


Q: How can I change my POSC password?

A: Revisit the Change a Password pdf format of provider-security-change-password.pdf
job aid for detailed instructions on changing your password. To view all POSC job aids, go to, click on Need Additional Training, then on Get Trained.


Q: I am having trouble creating a subordinate ID for POSC access. Where can I go for help?

A: Only the primary user and backup primary user can create a subordinate ID. The primary user should revisit the Create Subordinate Accounts pdf format of provider-security-create-accts.pdf
job aid to get information about establishing additional access for your users.


Q: I am a primary user and need to change my account information. What should I do?

A: Log in to the Virtual Gateway using;the ID for the account that needs to be changed. Click on Manage My Profile to update your ID information.


Q: How do I deactivate POSC access for a user?

A: Only the primary user and backup primary user can deactivate POSC access for a user. The primary user or backup primary user must contact MassHealth Customer Service at or call 1-800-841-2900. The representative will ask for the following information: primary/subordinate user Login ID, name (first and last), e‑mail address, and reason for change. The representative will use this information to update system data.


Q: What happens if an organization's primary user leaves? Can providers reset their POSC password for a new primary user?

A: There are two options for resetting the password. The first option is that the primary user can change the data on the primary user profile and provide the new user with the information. However, if he or she chooses this option, the user name remains the same. The second option is that the primary user can contact MassHealth Customer Service at 1-800-841-2900 to set up a new user ID and password.


Q: If a primary user creates a subordinate ID for one of their staff and someone else tries to establish an ID for that same person, what happens?

A: The system will not allow a second ID to be created with the same attributes. When the application for creation of a subordinate ID is completed, the system prompts the user to provide the last four digits of his or her social security number. This information is necessary to prevent duplication. If you are still experiencing duplication errors, contact MassHealth Customer Service at or 1-800-841-2900.


Q: I am having trouble submitting my MMQ batch files through the POSC and keep getting a "you are not authorized" message.

A: Your primary user should confirm that the user (that is, the submitter) is set up with the subordinate user roles "Batch File Submit and Download" and "Manage MMQ." The "Batch File Submit and Download" role allows the user the ability to upload a file and download a response.

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Service Authorizations (PA and PAS)


Q: Why doesn't APAS work?

A: The Automated Prior Authorization System (APAS) was retired on May 8, 2009. Providers must now submit requests for prior authorization (PA) through the POSC.


Q: What is the number I should use to fax PA requests and PA attachments to MassHealth?

A: Providers who have scanning capability should submit their PA requests and attachments electronically. (See the following two questions for more details on electronic submissions.) Providers who do not have scanning capability should contact MassHealth Customer Service at 1-800-841-2900 to inquire about an eFax account. EFax works like an ancillary scanner, preparing documents for electronic submission. Unfortunately, only a limited number of eFax accounts can be established. If you already have electronic scanning capability, MassHealth encourages you to use it. Providers experiencing difficulty with their eFax transmissions should contact MassHealth Customer Service as well.


Q: The drop-down field for selecting a transmission code under the Attachment tab within the PA entry application in NewMMIS lists several options. How do I know which one to use to submit my PA requests?

A: Providers submitting electronic PA requests must select the "electronically only" option. Do not select any other option from this field. The way to send a PA request and its associated attachments is either electronically (submitting the PA request electronically with electronic versions of the attachments) or on paper (submitting the paper PA-1 form along with any needed paper attachments).


Q: What is the Control Number field located under the Attachment tab in the PA entry application in NewMMIS, and am I required to complete it?

A: The Control Number field is a HIPAA standard request and it is related to the transmission code (AA or available by request on provider site). MassHealth does not accept Transmission Code AA, however, so you should leave this field blank.


Q: The second page of the PA-1 form instructs providers from the western region to send their paper PA requests to P.O. Box 9154. I'm not sure which region I fall into, can you be more specific?

A: It's best, if you have the capability, to submit your requests electronically through the POSC. However, if that option is not available to you, please mail your PA requests on paper to MassHealth, Hingham, MA 02043 at the following P.O. boxes based on your location: P.O. Box 9153 (the western region address) if you are located in Worcester, Berkshire, Hampden, Hampshire, or Franklin counties. Boston-region providers should send their PA requests to P.O. Box 9154.

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Q: When billing on paper after the other insurer has been billed and I received an EOB (explanation of benefits) or EOMB (Explanation of Medicare Benefits), should I always submit a claim form?

A:Yes. The EOB or EOMB must accompany the UB-04 or CMS-1500 claim form. Any EOB or EOMB received without the accompanying claim form will be denied. Please make sure that the EOB or EOMB contains all detail line information for the claim.


Q: When billing on paper, how do I enter the carrier code information?

A: Carrier codes have been expanded to seven digits. Refer to Appendix C of all MassHealth provider manuals for the appropriate carrier codes. The carrier codes must be entered on the claim form. For the CMS-1500 claim form, enter the carrier codes in Box 9C or 11C. For the UB-04 claim form, enter the carrier code in Box 51A, B, or C. Note:For Box 60 A, B, and C, please remember to fill out the corresponding insurer's unique ID in the same sequence as you have in Box 51A, B, and C. If there is more than one EOB for the claim, write the appropriate carrier code on each EOB.


Q: What carrier code should I use for Medicare claims?

A: Enter 0084000 for institutional claims (Part A) and 0085000 for professional claims (Part B) for both paper and electronic submissions. Use carrier code 0084000 for Part B claims that are billed for institutional services paid through Part B.

For electronic submissions, use claim filing indicator "MA" for carrier code 0084000. Use "MB" for carrier code 0085000.


Q: Do I need to report a carrier code for a member who is enrolled in an MCO?

A: No. Carrier codes are no longer used to inform providers that a member is enrolled in an MCO. Refer to the Eligibility Verification System (EVS) for the member's assignment plan.


Q: For third-party-liability (TPL) exception billing (for example, a member's benefits are exhausted or the service does not meet the other payer's level of care standards), I used to use condition codes and patient status codes when billing under the legacy system. Where can they be found now?

A: Condition codes and patient status codes have been replaced with HIPAA adjustment reason codes or remark codes. Please see the appendix in your MassHealth provider manual called "Supplemental Instructions for Claims with Other Health Insurance" for TPL exception billing rules.


Q: What should I do when MassHealth denies my Medicare crossover claim or commercial insurance claim because the HCPCS or revenue code was not on the claim?

A:You must submit the MassHealth-required HCPCS or revenue code for all third-party-liability (TPL) claims even when the other payer does not require it.


Q: What should I do if my crossovers have been adjudicated by Medicare but have not been processed by MassHealth?

A:If 60 days have passed since Medicare adjudication, then submit the claim directly to MassHealth according to the applicable MassHealth billing instructions. If you have a significant volume of claims that continually do not cross over, please contact CST.


Q: How are my claims supposed to be priced when the member has other insurance, such as Blue Cross or Aetna?

A: Claims for members with other insurance will be paid the lesser of the member's liability including coinsurance, deductible, and co-payments OR the MassHealth rate minus the insurance payment, as described in MassHealth regulations at 130 CMR 450.317. See example below.

  • Provider Charge: $100
  • MassHealth Rate: $80
  • Insurance Payment: $60
  • Member's liability: $10
  • MassHealth should pay:
  • The MassHealth rate (without insurance payment): $80
  • Subtract the insurance payment: ($60)
  • Remaining balance (MassHealth liability): $20
  • Compare the remaining balance to the member's liability: $10
  • Pay lesser of the two = $10 (in this case, the member's liability).

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Trading Partner Testing


Q: How can I find out if my vendor has tested with MassHealth?

A: You can check the Trading Partner Testing Status Report at Click on Need Additional Information or Training, then on Information and Software for Electronic Transactions.


Q: I didn't test with MassHealth. How do I know if the electronic 837 file that I submit will go through?

A: If you have updated your electronic transactions based on the applicable NewMMIS companion guide, you may submit your electronic files in production. MassHealth will process your claims, but they may not process as expected if you haven't tested.


Q: What are the consequences of not having tested with MassHealth?

A: Although you can submit your claims to MassHealth electronically without testing, you cannot be certain that claims will be accepted by MassHealth or properly adjudicated through the system.


Q: How can I become a testing partner with MassHealth?

A: MassHealth has not yet resumed trading partner testing. However, if you are interested in testing with MassHealth at a later date, please call 1-888-824-3484 to schedule a test.


Q: Are instructions available on test-file requirements?

A: Yes. Refer to the MassHealth billing guides and companion guides (see Section 2.2 - Trading Partner Testing) at for instructions on how to submit a file to NewMMIS and a general introduction on the purposes of testing.

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This information is provided by MassHealth .