The Centers for Medicare and Medicaid Services (CMS) requires all trading partners who submit electronic transactions, to convert from Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010. All covered entities (health care providers, health plans, and health care clearing houses) must be HIPAA-compliant by January 1, 2012.

Milestone/Date

Activities

December 31, 2010Complete internal testing
January 1, 2011 - December 31, 2011Conduct trading partner testing
January 1, 2012Go live/fully compliant

On March 15, 2012, the Centers for Medicare & Medicaid Services Office of E-Health Standards and Services (OESS) announced that it will not initiate enforcement action for an additional three months, through June 30, 2012, against any covered entity that is required to comply with the updated transactions standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA): ASC X12 Version 5010, and NCPDP Versions D.0 and 3.0.

Please Note: MassHealth implemented 5010 on January 1, 2012, and no longer supports 4010 transaction processing. All new or existing MassHealth providers who have questions about the submission of 5010 files to MassHealth should contact the EDI Customer Service team at 1-800-841-2900, or e-mail their inquiry to EDI@MAhealth.net.

Please refer to the links below for more information about MassHealth's implementation of the 5010 standards. MassHealth will update this Web page as information becomes available.


Billing Guides

Bulletins

MassHealth Provider bulletins issued to support the implementation of the CMS mandate.

Companion Guides

MassHealth Companion Guides

EVSpc Version 5010

MassHealth EVSpc/EVScall  

Will be Terminated on 9/1/2015–
Is No Longer Available for Download

Reminder―MassHealth will terminate the use of its proprietary Eligibility Verification Software (EVSpc\EVScall) on Tuesday, September 1, 2015, and will not provide support for the software tool after that date. Additionally, any transaction submitted to MassHealth via the EVSpc or EVScall software after that date will be rejected.

The proprietary EVSpc/EVScall software does not currently display key eligibility messages related to a MassHealth member’s coverage. It is imperative that providers stop using EVSpc and EVScall immediately and transition to the POSC or one of the other access methods.

Important Information—All MassHealth providers were notified on August 18, 2014, to stop using EVSpc to verify member eligibility, as the software tool does not provide eligibility notifications, warnings, and other important messages about MassHealth members that are provided by other MassHealth eligibility access methods noted below. Pursuant to that notification, you must transition to one of the eligibility verification methods available on the POSC or via Automated Voice Response (AVR). If you continue to use the software tool, EOHHS is not responsible for any action or inaction taken based on the information or lack of information provided by this tool, and will not be liable to you or any third party for any consequential, indirect, incidental, reliance, or special damages including, but not limited to, lost profits, even if EOHHS has been advised of the possibility of such damages. To the maximum extent permitted by applicable law, EOHHS disclaims all warranties, conditions, representations, or guaranties of any kind—express, implied, statutory, or otherwise, including but not limited to, any implied warranties or conditions of satisfactory quality or fitness for a particular purpose.

The following functionality will be terminated.

Note: ALL EVSpc and EVScall functionality will be terminated on September 1, 2015, including the following.

  • Support of information storage  
  • Submission of Health Care Benefit Inquiry & Response (270/271) transactions, via batch or real-time transactions
  • Submission of Health Care Claims Status Inquiry & Response (276/277) transactions, via batch or real-time transactions

Please note that the termination of the EVSpc/EVScall software does not affect any of the other options currently available to providers on the POSC or AVR.  

If you submit batch transactions, please follow the important eligibility submission guidelines below.

To ensure timely and efficient processing of transactions submitted by MassHealth providers and vendors in conformance with Phase I CORE 155: Eligibility and Benefits Batch Response Time Rules, and in accordance with HIPAA ASC X12 and MassHealth policy, providers and vendors must follow the following submission guidelines.

  1. ONLY check eligibility for those MassHealth members to whom you will actually provide service on that day or the following day.
  2. DO NOT submit your entire roster of MassHealth members unless you are providing services for your entire roster of members that day or the following day.
  3. DO NOT include more than 3,000 member requests in an eligibility batch-file request.
  4. DO NOT include more than 3,000 member requests in an eligibility transaction.  The 270/271 HIPAA Implementation Guide requires that the 270 transaction contain no more than 99 patient requests when using the transaction in batch mode though it allows other patient request limits to be set.  MassHealth agrees to the reasonable limit of up to a 3,000-member request per transaction and will reject transactions exceeding this limit beginning on May 10, 2015.  MassHealth reserves the right to modify this limit as required, in accordance with the HIPAA standard.  
  5. YOU MUST INCLUDE the member’s Medicaid Identification Number on the eligibility request, if known.
  6. POPULATE ALL subsequent eligibility requests with the member information received from MassHealth on the prior eligibility response, where applicable.

It is important that you follow these file submission guidelines to ensure a timely response to your file submission.

Visit www.mass.gov for more information about how to transition to another eligibility verification method, or contact the MassHealth Customer Service Center at 1-800-841-2900 to discuss transition options.

 

Healthcare Transactions Services-System-to-System Testing

If you currently submit batch transactions directly to MassHealth (270/271, 276/277, 820, 834, 835, 837) and are interested in submitting batch transactions to MMIS via the automated Healthcare Transactions Services (HTS) method (that is, system-to-system), please contact MassHealth Customer Service at 1-800-841-2900 or by e-mail at edi@mahealth.net.

Claim Adjustment Reason Codes and Remittance Advice Remark Codes

Job Aids

MassHealth has prepared the following job aids in support of the CMS 5010 mandate.

Provider Information

MassHealth Provider Services is committed to providing 5010 training and educational materials for the provider community to support the implementation of the CMS 5010 mandate.

Provider Training

5010 POSC Training for Claims

MassHealth is offering 5010 Webinar Training sessions to review changes to the Provider Online Service Center (POSC) direct data entry for Professional and Institutional claims. A Webinar for Professional claims is scheduled for Tuesday, January 24th at 10:00 A.M. and a Webinar for Institutional claims is scheduled for Tuesday, January 31st at 10:00 A.M.  Each Webinar will last approximately one hour.

In order to prepare for participation in the Webinar, we would like to offer some brief instructions that should be completed before the meeting.

Please note that it is necessary for you to be able to simultaneously access the Internet and use a phone line in order to participate in this Webinar. If capable of this, please follow the instructions below for joining the Webinar.

Joining instructions:

Joining the HP Virtual Room (Webinar Session)

  1. Please join the meeting at least 10 minutes before the start of the meeting.
  2. Go to http://www.hp.com/go/rooms.
  3. In the "Join a meeting" box in the left column, enter your full name and the following key: RPHDFVEGCL.  
  4. Click the "Go" button.
  5. A window will pop up and you will be automatically entered into the room. Please note that if you need to install any additional software or agreements, you will have to complete that part first then you will be entered into the room.

Accessing the Audio Component

  1. Dial 1-877-675-4345 to activate your participation in the conference call.
  2. Enter the Access Code 3859546301 # when prompted.

Vendor Testing Status as of 03/01/2012

MassHealth provides this data for informational purposes, so trading partners are aware of our testing efforts with billing intermediaries and software vendors.  Please contact your billing intermediary and/or software vendor directly to determine if you can proceed with claims submissions to MassHealth.

Please Note: This is the last update that will be made to this list as part of the 5010 post-implementation project phase. If you use a vendor on this list that has a status other than “Testing Completed Successfully,” you may call MassHealth Customer Service at 1-800-841-2900, to see if the vendor has taken the necessary steps to complete testing and are authorized to submit transactions on behalf of MassHealth providers.

5010 Vendor Testing Status  pdf format of 5010 Vendor Testing Status
txt format of                             5010 Vendor Testing Status

Frequently Asked Questions

Other Resources

TPL Appendices and Forms

Appendices

TPL Billing Resources and Information

In the 5010 environment, certain authorized provider types may use a new data element, “total noncovered amount,” to report noncovered charges for specific third-party-liability (TPL) exception conditions. Providers who are authorized to use a “total noncovered amount” when reporting specific TPL exception conditions are listed below. The exception instructions are located in the supplemental instructions in the applicable appendix of the provider manual, as indicated below.  

Provider Type

Appendix Location

Acute Inpatient HospitalsAppendix D of the Acute Inpatient Hospital Manual
Chronic Disease and Rehabilitation Inpatient HospitalsAppendix D of the Chronic Disease and Rehabilitation Inpatient Hospital Manual
Community Health CentersAppendix D of the Community Health Center Manual
Home Health AgenciesAppendix D of the Home Health Agency Manual
Mental Health CentersAppendix D of the Mental Health Center Manual
Nursing FacilitiesAppendix G of the Nursing Facility Manual
Psychiatric Inpatient HospitalsAppendix D of the Psychiatric Inpatient Hospital Manual

The above provider manual appendices contain specific MassHealth billing instructions for members who have Medicare or commercial insurance. The TPL appendices supplement the instructions contained in the HIPAA Implementation Guides, 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 that the other insurer has not paid the claim.

Forms

TPL forms have been revised to support changes in 5010.

 


This information is provided by MassHealth .