|December 31, 2010||Complete internal testing|
|January 1, 2011 - December 31, 2011||Conduct trading partner testing|
|January 1, 2012||Go 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.
- Changes to 5010 Billing Guides (PDF) Important! The 5010 billing guides have been updated. Please use this document to understand the latest changes that have been made to the billing guides since the previous versions were issued. These changes have also been incorporated into the most recent versions of the billing guides below.
- CMS-1500 Billing Guide (PDF)
- UB-04 Billing Guide (PDF)
- UB-04 Billing Guide for Residential Care Homes (PDF)
MassHealth Provider bulletins issued to support the implementation of the CMS mandate.
- All Provider Bulletin 222: 5010 Implementation Cutover
- All Provider Bulletin 219a: 5010 Implementation Readiness - Corrected
This bulletin has been corrected to reflect a revised date on which the EVSpc software and installation instructions will be available. The new date is December 12, 2011.
- All Provider Bulletin 216: HIPAA 5010 Diagnosis Code Requirement (PDF)
- All Provider Bulletin 213: Testing Readiness for CMS 5010 Mandate (PDF)
- All Provider Bulletin 210: 5010 Implementation Preparation (PDF)
- All Provider Bulletin 208: Overview of Key Changes to Be Implemented on January 1, 2012, to Support the Centers for Medicare & Medicaid Services 5010 Mandate (PDF)
- All Provider Bulletin 205: Implementation Approach for HIPAA X12 5010 Electronic Transactions (PDF)
- Physician Bulletin 91: Anesthesia Services and 5010 Requirements (PDF)
EVSpc Version 5010
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.
- For important information about transition options, please read Eligibility Verification Service Software (EVSpc) Available Transition Options.
- For important information on uploading batch files, please read NewMMIS Job Aid: Eligibility Verification – Upload Batch Files.
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.
- ONLY check eligibility for those MassHealth members to whom you will actually provide service on that day or the following day.
- 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.
- DO NOT include more than 3,000 member requests in an eligibility batch-file request.
- 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.
- YOU MUST INCLUDE the member’s Medicaid Identification Number on the eligibility request, if known.
- 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 email@example.com.
Claim Adjustment Reason Codes and Remittance Advice Remark Codes
- Claim Adjustment Reason Codes and Remittance Advice Remark Codes (CARCs and RARCs) file size 1MB file size 2MB
- Claims Adjustment Reason Codes and Remittance Advice Remark Codes – CHANGE LOG
MassHealth has prepared the following job aids in support of the CMS 5010 mandate.
- Institutional Claim Submission to MassHealth with Coordination of Benefits Information (PDF)
- Professional Claim Submission to MassHealth with Coordination of Benefits Information (PDF)
- Institutional Claim Submission with MassHealth (PDF)
- Professional Claims Submission with MassHealth (PDF)
- Submitting a Hospice Claim for Room and Board Charges (PDF)
- Supplemental Instructions for MassHealth Dual Eligible Members with Medicare Part B Coverage Only (PDF)
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 Association Feedback on 5010 Implementation
- Diagnosis Code Tips for All Providers
- Critical 5010 Testing Timeline (PDF)
- MassHealth 5010 Key Concepts (PDF)
- Selected Slides From November 10, 2010 Presentation (PDF)
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 the HP Virtual Room (Webinar Session)
- Please join the meeting at least 10 minutes before the start of the meeting.
- Go to www.myroom.hpe.com
- In the "Join a meeting" box in the left column, enter your full name and the following key: RPHDFVEGCL.
- Click the "Go" button.
- 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
- Dial 1-877-675-4345 to activate your participation in the conference call.
- 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.
Frequently Asked Questions
- 5010 EDI Questions and Answers (PDF)
- Most Common 5010 File Submission Errors
- Quick Tips for Submitting 5010 Test Files to MassHealth
- Vendor Session Questions and Answers (PDF)
- The Centers for Medicare & Medicaid Services (CMS) Web Site
- CMS National Education Calls
- CMS Educational Resources
- WEDI Information
TPL Appendices and Forms
- AIH-47: Revised Appendix D
- CDR-26: Revised Appendix D
- CHC-92: Revised Appendix D
- HHA-45: Revised Appendix D
- MHC-44: Revised Appendix D
- NF-58: Revisions to Appendices D and G
- PIH-20: Revised Appendix D
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.
|Acute Inpatient Hospitals||Appendix D of the Acute Inpatient Hospital Manual|
|Chronic Disease and Rehabilitation Inpatient Hospitals||Appendix D of the Chronic Disease and Rehabilitation Inpatient Hospital Manual|
|Community Health Centers||Appendix D of the Community Health Center Manual|
|Home Health Agencies||Appendix D of the Home Health Agency Manual|
|Mental Health Centers||Appendix D of the Mental Health Center Manual|
|Nursing Facilities||Appendix G of the Nursing Facility Manual|
|Psychiatric Inpatient Hospitals||Appendix 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.
TPL forms have been revised to support changes in 5010.
- TPL Exception Form
- TPL Attachment Form (PDF)
This information is provided by MassHealth .