Important. Please Read MMIS Notices - by Function

Date

Title

Comments

The MMIS POSC, including the internal MMIS application, Voice Response application, EVSpc, MAPIR (Medical Assistance Provider Incentive Repository), and all eligibility services will be unavailable from 4:00 am to 7:00 am Sunday, 5/19, due to system maintenance.

If you have any questions please contact the EHS Customer Support Center at 617-367-5500 or email SystemsSupporthelpdesk@Massmail.state.ma.us.

Event: Payment Error Rate Measurement (PERM) Provider Education Webinar
Date: Tuesday, May 21, 2013
Time: 3:00-4:00 pm ET

The PERM program is designed to measure improper payments in the Medicaid and Children’s Health Insurance Program (CHIP) programs, as required by the Improper Payments Information Act (IPIA) of 2002. This is one of four PERM Provider Webinar/Conference calls during PERM Cycle 2 (2013), hosted by the Centers for Medicare & Medicaid Services (CMS).

Webinar participants will learn about:

-The PERM process and provider responsibilities during a PERM review
-Frequent mistakes and best practices
-Electronic Submission of Medical Documentation (esMD program)

To join the Webinar:

Audio: 1-877-267-1577, Meeting ID# 4964

Webinar: https://webinar.cms.hhs.gov/permcycle2web1/

To test your connection in advance, launch https://webinar.cms.hhs.gov/common/help/en/support/meeting_test.htm

Presentation materials and participant call-in information are available at the cms.gov website.

For certain Community Health Centers that are also MassHealth Mental Health Center providers, claims that were submitted with Mental Health codes 90832, 90833, 90834, 90836 and 90791 were denied erroneously with Edit 4801 – PROCEDURE NOT COVERED BY PROVIDER CONTRACT. This issue has been resolved and the claims have been reprocessed. The reprocessed claims may appear on this or future Remittance Advices. No action is required by providers.

For questions, please contact MassHealth Customer Service at providersupport@mahealthnet or 1-800-841-2900.

MassHealth is reminding Transportation providers to submit claims with valid modifiers. Claims that are submitted with invalid modifiers will deny with Edit 251 - FIRST MODIFIER NOT COVERED and/or Edit 252 – SECOND MODIFIER NOT COVERED.

Transportation providers must use service codes and modifiers that accurately reflect the services provided.

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

MassHealth has posted the following publications on the MassHealth website:

Provider Bulletins from April 2013:

-Acute Inpatient Hospital Bulletin 147: Centralization of Receipt of Senior Medical Benefit Request Forms for Individuals Residing in and Entering a Long-Term-Care Facility

-Community Health Center Bulletin 75: Centralization of Receipt of Senior Medical Benefit Request Forms for Individuals Residing in and Entering a Long-Term-Care Facility

-Long-Term Care Facility Bulletin 107: Annual Accounting for Personal Needs Account (PNA) Funds

-Nursing Facility Bulletin 136: Centralization of Receipt of Senior Medical Benefit Request Forms for Individuals Residing in and Entering a Long-Term-Care Facility

-School-Based Medicaid Bulletin 23: Claiming Medicaid Reimbursement for Students Placed in the Judge Rotenberg Center

Transmittal Letters from April 2013:

-AIH-48: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-CHC-96: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-CDR-28: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-MHC-45: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-NF-59: Revised Appendix G - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-PIH-21: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

You can download a copy of a Bulletin or Transmittal Letter from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when Bulletins and Transmittal Letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

In accordance with 130 CMR 437.412(C), Hospice providers must submit a completed and signed MassHealth Hospice Election Form before billing for members who elect hospice services. You must complete this form whenever a MassHealth member chooses to elect or stop hospice services, to change hospice providers or when a member is disenrolled from hospice.

If you do not submit a completed and signed Hospice Election Form, the member will not be properly coded to the hospice provider ID/service location. Claims will be denied with Edit 2800 – MEMBER NOT TIED TO HOSPICE FOR DATE OF SERVICE.

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

-MassHealth PID/SL
-MassHealth member ID
-Hospice disenrollment reason(section D, if applicable)

To download a copy of the MassHealth Hospice Election Form, go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/ and then click on MassHealth Provider Forms.

You may 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

For questions, contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Hospice providers are reminded to check member eligibility in EVS before submitting completed hospice election forms to the hospice unit for processing. When checking member eligibility in EVS, providers are reminded to click on both the member information and eligibility information tabs.  The eligibility information tab includes detailed information, such as, restrictive messages, other insurance, coverage types, managed care and long term care.

In accordance with 130 CMR 508.000, members in MCO and PCC plans are subject to specific requirements regarding hospice enrollment. The hospice benefit is a covered service for members enrolled in SCO and PACE plans and payment for the hospice benefit is the responsibility of the SCO or PACE plan. Providers should contact SCO or PACE plans directly for hospice billing instructions at the telephone numbers listed on the eligibility screen.

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

Independent Nurses – Billing Weekend Nursing Services

Independent Nurses are reminded that they should not use the UJ (NIGHT) modifier to indicate nursing services on a weekend.  The weekend rate will automatically be paid for nursing services provided on the weekend.

Please refer to Subchapter 6 of the Independent Nurses Manual for definitions of nursing hours and modifiers.  Independent Nurse providers must use service codes that accurately reflect the nursing services provided.

Rates for home health nursing services can be found under Home Health Services (114.3 CMR 50.00) at www.mass.gov/eohhs/gov/laws-regs/hhs/regs.html. Click on Regulations.

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

Providers are reminded that only emergency services that are necessary to treat an acute medical condition requiring immediate care are allowed for members who have MassHealth limited coverage as described in 130 CMR 450.105 (G)(1):

Covered Services. For MassHealth limited coverage members (please see 130 CMR 505.008 AND 519.009), MassHealth will only pay for the treatment of a medical condition (including labor and delivery) that manifests itself by acute symptoms of sufficient severity that the absence of immediate medical attention reasonably could be expected to result in:

(A) Placing the member’s health in serious jeopardy,

(B) Serious impairment to bodily functions, or

(C) Serious dysfunction of any bodily organ or part.

For questions, please contact MassHealth Customer Services at 1-800-841-2900 or email your inquiry to providersupport@mahealth.net.

MassHealth has posted the following publications on the MassHealth website:

Transmittal Letters from March 2013:

-ALL-199: Revised Regulations about Electronic 90-Day Waiver and Final Deadline Appeals file size 5MB

-ALL-198: Emergency Adoption of Mental Health Parity Regulations

-FAS-26: 2013 HCPCS

You can download a copy of a Bulletin or Transmittal Letter from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when Bulletins and Transmittal Letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

Providers are reminded that only emergency services that are necessary to treat an acute medical condition requiring immediate care are allowed for members who have MassHealth Limited Coverage as described in 130 CMR 450.105 (G)(1):

Covered Services. For MassHealth limited coverage members (please see 130 CMR 505.008 AND 519.009), MassHealth will only pay for the treatment of a medical condition (including labor and delivery) that manifests itself by acute symptoms of sufficient severity that the absence of immediate medical attention reasonably could be expected to result in:

(A) Placing the member’s health in serious jeopardy,

(B) Serious impairment to bodily functions, or

(C) Serious dysfunction of any bodily organ or part.

MassHealth will cover the following Dental Codes for members with limited coverage:

D0140, D0220, D0230, D0330, D7140, D7210 AND D9110

For questions, please contact MassHealth Dental Customer Services AT 1-800-325-5231 or email your inquiry to: INQUIRIES@MASSHEALTH-DENTAL.NET.

Therapy providers are reminded that they must follow the billing guidelines in Subchapter 6, Service Codes and Descriptions. Refer to Transmittal Letter THP-25, dated June 2011.  Modifier HA must be used when billing therapy evaluation service codes 97001, 97003 and 92506 for members aged 21 and under. Refer to Transmittal Letter THP-20, dated November 2003. To access these Transmittal Letters, go to www.mass.gov/masshealthpubs.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

MassHealth has identified underpayments of ACA section 1202 enhancement rates on certain claims submitted between January 01, 2013-March 01, 2013. The enclosed remittance advice may contain claims that were systematically adjusted to pay the enhanced fee. We apologize for the inconvenience.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

MassHealth understands that due to a unit-counting issue, MMIS inappropriately adjudicated a number of Early Intervention (EI) provider claims for service code T1024 (EI assessment) with edit 8155 (limit 40 units in 12 months), not allowing for the maximum of 40 units per 12- month period.

To appropriately allow the maximum of 40 units per 12-month period, units of T1024 for dates of service on or after July 01, 2011 are being counted based on a MOVING DATE OF SERVICE (DOS) anniversary date, with MassHealth beginning to count the 40 units based on the first DOS for which the claim for T1024 is filed. For example, if an EI provider submits an a claim for T1024 with the first DOS of March 06, 2013, the EI provider may then bill an accumulation of 40 units of T1024 during the 12-month period beginning on DOS March 06, 2013 and ending March 05, 2014. After March 05, 2014 and having reached the 12-month mark from the first DOS on the claim, MassHealth will begin counting another 40 units toward the next 12-month period, based on the DOS of the T1024 claim that is received after March 05, 2014. For example, if a claim is submitted with the first DOS of May 06, 2014, then MassHealth will again begin counting up to 40 units in the 12-month period beginning May 06, 2014 and ending May 05, 2015.

MassHealth will systematically reprocess previously adjudicated claims for T1024 due to edit 8155, for DOS July 01, 2011 and following, on future remittance advices. No action is required on the part of the provider.

We apologize for any inconvenience this may have caused. For questions, including information on the appeals process, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Please be advised that the Executive Office of Health and Human Services (EOHHS) has updated the Hospice Rates for MassHealth Hospice Providers, pursuant to regulation 101 CMR 343.00. The updated Hospice rates are effective for dates of service October 01, 2012 –September 30, 2013. MassHealth will process mass retro rate adjustments in April 2013. No further action is required by Hospice Providers.

If you have questions, contact MassHealth Customer Service at 1-800-841-2900. Updated Hospice Rates are available at EOHHS’s website at www.mass.gov/eohhs/gov/laws-regs/hhs/regs.html.

MassHealth has posted the following publications on the MassHealth website:

Provider Bulletins from February 2013:

-Acute Outpatient Hospital Bulletin 28: Drug Screen/Quantitative Drug Test Claim Edit; Drug Screens Performed For Residential Monitoring
-All Provider Bulletin 233: Revisions to the 90-Day Waiver Procedures
-All Provider Bulletin 232: Revisions to the Final Deadline Appeal Procedures
-All Provider Bulletin 231: Payment Error Rate Measurement (PERM) Project
-Community Health Center 74: Drug Screen/Quantitative Drug Test Claim Edit; Drug Screens Performed For Residential Monitoring
-Independent Clinical Laboratory Bulletin 9: Drug Screen/Quantitative Drug Test Claim Edit; Drug Screens Performed For Residential Monitoring
-Physician Bulletin 94: Drug Screen/Quantitative Drug Test Claim Edit; Drug Screens Performed For Residential Monitoring

Transmittal Letters from February 2013:

-ALL-197: Revised Appendix C

You can download a copy of a Bulletin or Transmittal Letter from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when Bulletins and Transmittal Letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

As a MassHealth provider, you are reminded that, in accordance with MassHealth regulation 130 CMR 450.223(B), you must notify MassHealth in writing within 14 days of any profile information that has changed since your initial enrollment. This includes, but is not limited to, changes in ownership or control, criminal convictions, address changes or license status. Failure to notify MassHealth constitutes a breach of the provider contract and may result in termination of the provider contract or other sanctions. The absence of notification constitutes confirmation of no changes.

To submit changes through the Provider Online Service Center (POSC), go to www.mass.gov/masshealth/providerservicecenter and click on the Manage Provider Information link, then on Maintain Profile and then on Update Your MassHealth Profile. Providers without Internet access may submit changes in writing to Provider Enrollment and Credentialing, PO Box 9118, Hingham, MA 02043.

In response to the flu vaccine crisis, MassHealth wants to inform physicians, group practices and independent nurse practitioners that you will be reimbursed for privately-purchased flu vaccine if you exhaust your state-provided supply from local boards of health or the Massachusetts Department of Public Health (MDPH).

In accordance with 130 CMR 433.443 (c)(2)(a), reimbursement for privately-purchased vaccine can be obtained by using the following codes: 90655, 90656, 90657, 90658, 90660, 90661 and 90662.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

In response to the flu vaccine crisis, MassHealth wants to inform community health centers that they will be reimbursed for privately-purchased flu vaccine if they exhaust their state-provided supply from local boards of health or the Massachusetts Department of Public Health (MDPH).

Reimbursement for privately-purchased vaccine can be obtained by using the following codes: 90655, 90656, 90657, 90658, 90660, 90661 and 90662.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

In response to the flu vaccine crisis, MassHealth wants to inform limited services clinics that they will be reimbursed for privately-purchased flu vaccine if they exhaust their state-provided supply from local boards of health or the Massachusetts Department of Public Health (MDPH).

Reimbursement for privately-purchased vaccine can be obtained by using the following codes: 90655, 90656, 90657, and 90658.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

All Provider Bulletin 225, dated April 2012, communicates the circumstances in which to use each Delay Reason Code when submitting Direct Data Entry (DDE) claims via the Provider Online Service Center (POSC). Delay Reason Code 11 – OTHER includes, but is not limited to, NCCI/MUE related reviews and special circumstances. DDE claims for submissions of Final Deadline Appeals (9) or 90-Day Waiver Requests (1, 4 or 8) should be submitted with the appropriate Delay Reason Code, as noted. Additionally, claims submitted with TPL attachments, Sterilization forms, Hysterectomy forms or Invoices are not required to submit with Delay Reason Code 11 unless the circumstance is specifically outlined in the bulletin referenced above.

Please remember to include a brief cover letter as to why special handling is needed and include the supporting documentation, as well as any applicable remittance advices, with your DDE claim submission. Erroneous selections of Delay Reason Codes may cause delays in claims processing or result in claims denials.

Go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/. Click on Provider Bulletins, then 2012 Bulletins, then April. For questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

MassHealth understands that due to the October CMS NCCI quarterly update, MMIS has been denying Substance Abuse provider claims for service code H0020 (alcohol and/or drug services methadone administration and/or service) when more than one unit is billed, with denial edit 5930 (MUE units exceeded). MassHealth has reviewed this matter and has implemented a change to the billing procedures so that H0020 may only be used to bill Methadone Administration. Counseling services provided as part of the Methadone program should be billed separately with the codes listed below.

The new codes allowed for counseling are:

H0004 TF - Behavioral Health counseling and therapy (Methadone/Opioid counseling) per 15-minute unit (individual counseling, intermediate level of care, four units maximum per day)

T1006 HR - Alcohol and/or substance abuse services (Methadone/Opioid counseling) per 30-minute unit (family/couple counseling, two units maximum per day)

H0005 HQ - Alcohol and/or drug service group counseling by a clinician (Methadone/ Opioid counseling) per 45-minute unit (two units maximum per day)

The following codes, previously allowed for counseling, will no longer be valid effective January 16, 2013: H0020 TF, H0020 HR and H0020 HQ.

Providers who have denied claims with service code H0020 due to the MUE quarterly update must resubmit their claims using the new substance abuse counseling codes and modifiers. Updates to subchapter 6 of the Provider Manual are forthcoming. For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

The Chronic Disease and Rehabilitation Hospital Utilization Management Program (UMP) will begin post-payment reviews this month on inpatient claims. The UMP will send written correspondence to the hospitals identified for the post-pay review, listing the claims being reviewed.

The UMP will also request that hospitals submit medical records as needed, in accordance with MassHealth regulation at 130 CMR 450.205. Medical record requests will continue on a monthly basis. If you have any questions regarding the review process, please contact Martina McCormack, UMP Manager, at 617-847-3748.

MassHealth has posted the following publications on the MassHealth website:

Provider Bulletins from December 2012

• Nursing Facility Bulletin 135: Updates to Nursing Facility Pay for Performance (NF P4P) Program for Fiscal Year (FY) 2013
• All Provider Bulletin 230: Section 1202 Rates for Physicians Who Provide Primary Care Service

You can download a copy of a bulletin or transmittal letter from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when bulletins and transmittal letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

The POSC was designed with security protocols that allow access to a provider’s information by only authorized individuals. This process is accomplished with the assignment of a primary user for each provider. The primary user then has the responsibility to grant subordinate permissions to provider staff for the functions they need. The primary user is also required to maintain user IDs by removing access for those who leave the provider or change job functions.

Maintaining subordinate access is a requirement that is mandated by regulation to notify MassHealth of any change in information. If a primary user no longer has that role, the provider must assign a new primary user and remove the previous user’s access as necessary. Providers are not permitted to continue to use the primary user ID of someone who is no longer employed. Providers should audit their primary user(s) and subordinate(s) to be certain that they are up-to-date.

MassHealth has posted the following publications on the MassHealth website:

Provider Bulletins from December 2012

• All Provider Bulletin 230: Section 1202 Rates for Physicians Who Provide Primary Care Service

You can download a copy of a bulletin or transmittal letter from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when bulletins and transmittal letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

The Massachusetts Health Quality Partners (MHQP) has released the 2012 Pediatric and Adult Preventive Care Guidelines and Immunization Schedules. They can be accessed via the MHQP web site.

For Pediatric Preventive Care Recommendations, go to: www.mhqp.org/guidelines/pedPreventive/pedPreventive.asp?nav=041100

For Adult Preventive Care Guidelines, go to:
www.mhqp.org/guidelines/adultPreventive/adultPreventive.asp?nav=040900

MassHealth has implemented a processing change for Part B crossover claims billed by group practice providers.

As of 12/16/12, all Part B crossover claims submitted by group practice providers will be priced based on the rendering provider ID submitted in the claim detail. Previously, MassHealth priced these claims based on the billing provider ID. The rendering provider ID must be on file with MassHealth and is required on the claim submission. The following informational edits will appear on your remittance advice if the rendering provider ID is not on file or is not eligible to bill the service: Edit 1007 -DETAIL RENDERING PROVIDER I.D. NOT ON FILE or Edit 1002 -DTL PERFORMING PROV NOT ELIG AT SERV LOC FOR PROG.

Group practice providers are responsible for ensuring that all individuals who practice as rendering providers in the group are enrolled and active providers with MassHealth before claims may be submitted for payment. Failure to do so may result in claims denials.

Effective January 01, 2013, four (4) modifiers have been added to the list of modifiers that providers can use, when medically appropriate and in accordance with CMS regulations, to bypass National Correct Coding Initiative (NCCI) procedure code to procedure code (PTP) edits.

The following two new HCPCS modifiers will be added to the list of allowable PTP associated modifiers for Medicaid fee-for-service claims subject to the Practitioner (PRA) NCCI edits and Outpatient Hospital (OPH) NCCI edits:

LM – LEFT MAIN CORONARY ARTERY
RI – RAMUS INTERMEDIUS CORONARY ARTERY

The following two existing CPT modifiers will be added to the list of designated PTP-associated modifiers for use for Medicaid fee-for-service claims subject to PRA NCCI edits, but not for claims subject to OPH NCCI edits:

24 – UNRELATED MANAGEMENT AND EVALUATION SERVICE BY THE SAME PHYSICIAN DURING POST-OPERATIVE PERIOD
57 – DECISION FOR SURGERY

Note that these two modifiers have previously been allowable by MassHealth for purposes of bypassing global surgery edits. For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900. For general information on modifier use, please see Provider Bulletin 227.

Important Message about Third Party Liability Claims for Qualified Medicare Beneficiaries (QMB) Members with Medicare Advantage Plans

On 12/02/2012, MassHealth implemented a system change to allow third party liability claim payment for MassHealth non-covered services provided to MassHealth QMB members with Medicare Advantage Plan coverage. Claims processed on or after 12/02/2012 for MassHealth non-covered services provided to members with Medicare Advantage will be paid if there is a remaining MassHealth liability on the claim.

As a result of this change, providers may see the following new EOB codes on remittance advices:

1806 - PAID PATIENT RESPONSIBILITY AMOUNT (header)
1807 - PAID PATIENT RESPONSIBILITY AMOUNT (detail)

MassHealth plans to reprocess previously denied claims and will provide an update in a future message. For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Nursing Facility providers are reminded that they must follow the billing guidelines in Bulletin 133, dated May 2012, as well as the guidelines published in Transmittal Letter NF 58, dated December 2011, when billing claims for members with Medicare, Medicare Advantage and/or other insurance coverage.

Claims denying for Edit 2528 - POTENTIAL MEDICARE A IN FIRST 100 DAYS, Edit 2556 – POTENTIAL MEDICARE C IN FIRST 100 DAYS or Edit 2557 – POTENTIAL PRIVATE INSURANCE IN FIRST 100 DAYS can be resolved by following the instructions in the above-mentioned publications. Go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/ and click on the links for Bulletins and Transmittal Letters. For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Providers are advised that MassHealth has made enhancements on the POSC for all COB claim submissions.  Certain COB fields in the Coordination of Benefits and Procedure tabs will now auto-populate for you:

Coordination of Benefits Tab: In the “Coordination of Benefits (COB) Detail” panel, if the “Relationship to Subscriber,” is “18-Self”,  there is now an option to click “Populate Subscriber” which will auto-populate the following data fields that have already been entered on the “Billing and Service” tab:

-Subscriber Last Name

-Subscriber First Name

-Subscriber Address

-Subscriber City

-Subscriber State

-Subscriber Zip Code

Procedure tab: In the COB Line Details panel, the following data fields will auto-populate from the information that has been entered on the “Coordination of Benefits” tab and “Institutional/Professional Service Detail” panel:

-Carrier Code (if multiple carrier codes have been entered from the “Coordination of Benefits” tab, there will be a drop down to select the appropriate carrier code)

-Paid Units of Service

-Revenue Code (applies to Institutional claims)

-Procedure Code

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Effective 10/01/2012, service code 92340 (Fitting of spectacles, except for aphakia; monofocal) was included on the NCCI Medically Unlikely Edit list, limiting this service code to one unit per date of service. 

To receive payment for fitting two pairs of eyeglasses instead of bifocals for members, providers must now bill service code 92340 with a single unit on two claim lines.  The first claim line must be reported with no modifier and the second claim line with modifier 59 (Distinct procedural service).  For claims which have already denied under edit code 5930 (MUE Units Exceeded), please re-bill these claims as described above rather than submitting an appeal.

The 2013 Current Procedural Terminology (CPT) manual, published by the American Medical Association (AMA), has made some major changes to psychiatric procedure codes. 

The following codes, previously allowed for Mental Health Centers, will no longer be valid for dates of service after January 01, 2013: 90801, 90862, 90804, 90806, 90816 and 90818.  Medication Management services previously billed under 90862 should now be billed as an evaluation and management office visit (99213). 

New psychiatric codes covered for Mental Health Centers include:

90791 - Psychiatric Diagnostic Evaluation
90832 - Psychotherapy, 30 minutes with patient and/or family member
90833 - Psychotherapy, 30 minutes with patient and/or family member when performed with E&M service
90834 - Psychotherapy, 45 minutes with patient and/or family member
90836 – Psychotherapy, 45 minutes with patient and/or family member when performed with E&M service
99213 - Office or other outpatient visit for evaluation and management

Please refer to the 2013 CPT manual for details regarding these codes.

MassHealth understands that due to the recent CMS NCCI quarterly update, MMIS has been denying Early Intervention provider claims for service code T1015 –TL (clinic visit/encounter, all-inclusive) when more than one unit is billed, with denial edit 5930 (MUE units exceeded).

MassHealth has reviewed this matter and has implemented a change to address this issue to ensure that future Early Intervention claims for T1015 TL will process according to MassHealth regulations and as stated in subchapter 6 of the Early Intervention provider manual. We will systematically reprocess previously adjudicated claims for T1015 denied due to edit 5930 on future remittance advices. No action is required on the part of the provider.

We apologize for any inconvenience this may have caused. For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

New MassHealth Publications Posted on the Web

MassHealth has posted the following publications on the MassHealth website:

Provider Bulletins from November 2012

-All Provider Bulletin 229: Physician Designees and the Ambulance Medical Necessity Form   

-Nursing Facility Bulletin 134: Nursing Facility Pay for Performance (NF P4P) Program for 

 Fiscal Year (FY) 2013  

You can download a copy of a transmittal letter or bulletin from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when bulletins and transmittal letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

Effective Monday, December 3, 2012, providers who submit Prior Authorization (PA) requests via the MMIS Provider Online Service Center (POSC) will no longer be able to add a line item to a previously adjudicated PA. 

To modify an existing PA on the POSC, providers must submit a NEW PA request for the procedure code and the number of units being requested for review.  When submitting a new PA request for an adjustment or modification, providers must enter ADJUSTMENT/MODIFICATION in the PROVIDER COMMENTS section and, if applicable, include the active PA number to be adjusted/modified along with units already used/billed. With the exception of adjustment requests to change the size of absorbent products, the provider must include all required documentation to justify the medical necessity of the request, including a letter signed by the member’s prescribing provider that states the reason for the adjustment/modification and prescription, if required.

Upon receipt of the adjustment/modification request, the Prior Authorization Unit (PAU) will review for medical necessity and adjudicate the request as appropriate.

If you have any questions regarding this information, please contact the PAU at 1-800-862-8341 or PriorAuthorization@umassmed.edu.

MassHealth has posted the following publications on the MassHealth website:

Transmittal Letters from October 2012

- FPA-47: 2012 HCPCS

- ALL-196: Updates to Appendices U and V to All Provider Manuals to Reflect Changes in DPH-Designated Serious Reportable Events (SREs) and CMS-Designated Provider Preventable Conditions (PPCs)

- PRT-24: Changes to MassHealth Prosthetic Regulations

You can download a copy of a transmittal letter or bulletin from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when bulletins and transmittal letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

MassHealth is currently experiencing delays in processing suspended claims submitted via Direct Data Entry (DDE) with Delay Reason Code 11.  In order to maintain a 120-day suspension period for edit 829 - NCCI APPEAL/SPECIAL HANDLE UNDER REVIEW, MassHealth is working diligently to review claims requiring special handling.

Providers are advised to select the appropriate delay reason code for special handling claims, as outlined in All Provider Bulletin 225, April 2012, Special Circumstances for Electronic Claims. Erroneous selections may cause delays in review and claims processing or claims denials.  Go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/.  Click on Provider Bulletins, then 2012 Bulletins, then April.

We apologize for the delay and thank you for your patience.  If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

New Bulletin information added since first posted on 10/05/12:

MassHealth has posted the following publications on the MassHealth website:

Transmittal Letters from September 2012

• DEN-89: Corrections to Service Codes
• ORT-23: 2012 HCPCS
• PHY-137: Certified Registered Nurse Anesthetists
• PRT-23: 2012 HCPCS

Provider Bulletins for September 2012

• Acute Inpatient Hospital Bulletin 146: Notification of Birth (NOB-1) Form Update
• Acute Inpatient Hospital Bulletin 145: Express Lane Renewal Process
• Acute Outpatient Hospital Bulletin 27: New Department of Revenue (DOR) Job Update Process
• Acute Outpatient Hospital Bulletin 26: Express Lane Renewal Process
• Community Health Center Bulletin 73: New Department of Revenue (DOR) Job Update Process
•  Community Health Center Bulletin 72: Express Lane Renewal Process
• Home Health Agency Bulletin 48: Introduction of the New Homebound Assessment Form
• Psychiatric Inpatient Hospital Bulletin 23: Annual Accounting of Personal Needs Allowances

You can download a copy of a transmittal letter or bulletin from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when bulletins and transmittal letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

Providers are reminded to verify member eligibility using the Provider Online Service Center (POSC) before rendering services.

In addition, before submitting claims, please be sure to check all tabs and view the member's eligibility details by clicking on the date range to verify whether the member has other health insurance, is assigned to a Primary Care Clinician (PCC) Provider for referrals or has any other eligibility restrictions.

The Verify Member Eligibility online job aid offers instructions for this function. Go to 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. Under Eligibility Verification, click Verify Member Eligibility.

Remember to check the global time frame attached to the service code being billed for a member in order to avoid the following edits:

8175 – SERVICE PROVIDED ON THE SAME DAY OF A GLOBAL SURGICAL PROCEDURE IS INCLUDED IN FEE AMOUNT

8176 – SERVICE PROVIDED ON THE DAY OF AND DURING 10-DAY GLOBAL SURGICAL PROCEDURE INCLUDED

8177 – SERVICE PROVIDED DAY BEFORE AND DURING 90-DAY GLOBAL SURGICAL PROCEDURE INCLUDED

8253 – VISIT AND SURGERY NOT ALLOWED SAME DAY/SAME POS

Please refer to Payment for Global Surgical Package regulations (130 CMR 433.452(B)) located in the MassHealth Physician Manual. For additional information about the National Correct Coding Initiative (NCCI) and associated modifiers, please refer to MassHealth All Provider Bulletin 209 (April 2011) and All Provider Bulletin 227 (June 2012).

MassHealth has posted the following publications on the MassHealth website:

Transmittal Letters from September 2012

-DEN-89: Corrections to Service Codes
-ORT-23: 2012 HCPCS
-PHY-137: Certified Registered Nurse Anesthetists 
-PRT-23: 2012 HCPCS

Provider Bulletins for September 2012
-Home Health Agency Bulletin 48: Introduction of the New Homebound Assessment Form
-Psychiatric Inpatient Hospital Bulletin 23: Annual Accounting of Personal Needs Allowances

Date

Title

Comments

Event: Payment Error Rate Measurement (PERM) Provider Education Webinar
Date: Tuesday, May 21, 2013
Time: 3:00-4:00 pm ET

The PERM program is designed to measure improper payments in the Medicaid and Children’s Health Insurance Program (CHIP) programs, as required by the Improper Payments Information Act (IPIA) of 2002. This is one of four PERM Provider Webinar/Conference calls during PERM Cycle 2 (2013), hosted by the Centers for Medicare & Medicaid Services (CMS).

Webinar participants will learn about:

-The PERM process and provider responsibilities during a PERM review
-Frequent mistakes and best practices
-Electronic Submission of Medical Documentation (esMD program)

To join the Webinar:

Audio: 1-877-267-1577, Meeting ID# 4964

Webinar: https://webinar.cms.hhs.gov/permcycle2web1/

To test your connection in advance, launch https://webinar.cms.hhs.gov/common/help/en/support/meeting_test.htm

Presentation materials and participant call-in information are available at the cms.gov website.

For certain Community Health Centers that are also MassHealth Mental Health Center providers, claims that were submitted with Mental Health codes 90832, 90833, 90834, 90836 and 90791 were denied erroneously with Edit 4801 – PROCEDURE NOT COVERED BY PROVIDER CONTRACT. This issue has been resolved and the claims have been reprocessed. The reprocessed claims may appear on this or future Remittance Advices. No action is required by providers.

For questions, please contact MassHealth Customer Service at providersupport@mahealthnet or 1-800-841-2900.

MassHealth is reminding Transportation providers to submit claims with valid modifiers. Claims that are submitted with invalid modifiers will deny with Edit 251 - FIRST MODIFIER NOT COVERED and/or Edit 252 – SECOND MODIFIER NOT COVERED.

Transportation providers must use service codes and modifiers that accurately reflect the services provided.

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

MassHealth has posted the following publications on the MassHealth website:

Provider Bulletins from April 2013:

-Acute Inpatient Hospital Bulletin 147: Centralization of Receipt of Senior Medical Benefit Request Forms for Individuals Residing in and Entering a Long-Term-Care Facility

-Community Health Center Bulletin 75: Centralization of Receipt of Senior Medical Benefit Request Forms for Individuals Residing in and Entering a Long-Term-Care Facility

-Long-Term Care Facility Bulletin 107: Annual Accounting for Personal Needs Account (PNA) Funds

-Nursing Facility Bulletin 136: Centralization of Receipt of Senior Medical Benefit Request Forms for Individuals Residing in and Entering a Long-Term-Care Facility

-School-Based Medicaid Bulletin 23: Claiming Medicaid Reimbursement for Students Placed in the Judge Rotenberg Center

Transmittal Letters from April 2013:

-AIH-48: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-CHC-96: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-CDR-28: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-MHC-45: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-NF-59: Revised Appendix G - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

-PIH-21: Revised Appendix D - Coordination of Benefits Direct Data Entry Enhancements for the Provider Online Service Center

You can download a copy of a Bulletin or Transmittal Letter from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when Bulletins and Transmittal Letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

In accordance with 130 CMR 437.412(C), Hospice providers must submit a completed and signed MassHealth Hospice Election Form before billing for members who elect hospice services. You must complete this form whenever a MassHealth member chooses to elect or stop hospice services, to change hospice providers or when a member is disenrolled from hospice.

If you do not submit a completed and signed Hospice Election Form, the member will not be properly coded to the hospice provider ID/service location. Claims will be denied with Edit 2800 – MEMBER NOT TIED TO HOSPICE FOR DATE OF SERVICE.

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

-MassHealth PID/SL
-MassHealth member ID
-Hospice disenrollment reason(section D, if applicable)

To download a copy of the MassHealth Hospice Election Form, go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/ and then click on MassHealth Provider Forms.

You may 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

For questions, contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Hospice providers are reminded to check member eligibility in EVS before submitting completed hospice election forms to the hospice unit for processing. When checking member eligibility in EVS, providers are reminded to click on both the member information and eligibility information tabs.  The eligibility information tab includes detailed information, such as, restrictive messages, other insurance, coverage types, managed care and long term care.

In accordance with 130 CMR 508.000, members in MCO and PCC plans are subject to specific requirements regarding hospice enrollment. The hospice benefit is a covered service for members enrolled in SCO and PACE plans and payment for the hospice benefit is the responsibility of the SCO or PACE plan. Providers should contact SCO or PACE plans directly for hospice billing instructions at the telephone numbers listed on the eligibility screen.

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

Independent Nurses – Billing Weekend Nursing Services

Independent Nurses are reminded that they should not use the UJ (NIGHT) modifier to indicate nursing services on a weekend.  The weekend rate will automatically be paid for nursing services provided on the weekend.

Please refer to Subchapter 6 of the Independent Nurses Manual for definitions of nursing hours and modifiers.  Independent Nurse providers must use service codes that accurately reflect the nursing services provided.

Rates for home health nursing services can be found under Home Health Services (114.3 CMR 50.00) at www.mass.gov/eohhs/gov/laws-regs/hhs/regs.html. Click on Regulations.

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

In accordance with 130 CMR 437.412(C), Hospice providers must submit a completed and signed MassHealth Hospice Election Form before billing for members who elect hospice services. You must complete this form whenever a MassHealth member chooses to elect or stop hospice services, to change hospice providers or when a member is disenrolled from hospice.

If you do not submit a completed and signed Hospice Election Form, the member will not be properly coded to the hospice provider ID/service location. Claims will be denied with Edit 2800 – MEMBER NOT TIED TO HOSPICE FOR DATE OF SERVICE.

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

-MassHealth PID/SL
-MassHealth member ID
-Hospice disenrollment reason(section D, if applicable)

To download a copy of the MassHealth Hospice Election Form, go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/ and then click on MassHealth Provider Forms.

You may 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

For questions, contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Hospice providers are reminded to check member eligibility in EVS before submitting completed hospice election forms to the hospice unit for processing. When checking member eligibility in EVS, providers are reminded to click on both the member information and eligibility information tabs.  The eligibility information tab includes detailed information, such as, restrictive messages, other insurance, coverage types, managed care and long term care.

In accordance with 130 CMR 508.000, members in MCO and PCC plans are subject to specific requirements regarding hospice enrollment. The hospice benefit is a covered service for members enrolled in SCO and PACE plans and payment for the hospice benefit is the responsibility of the SCO or PACE plan. Providers should contact SCO or PACE plans directly for hospice billing instructions at the telephone numbers listed on the eligibility screen.

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

Independent Nurses – Billing Weekend Nursing Services

Independent Nurses are reminded that they should not use the UJ (NIGHT) modifier to indicate nursing services on a weekend.  The weekend rate will automatically be paid for nursing services provided on the weekend.

Please refer to Subchapter 6 of the Independent Nurses Manual for definitions of nursing hours and modifiers.  Independent Nurse providers must use service codes that accurately reflect the nursing services provided.

Rates for home health nursing services can be found under Home Health Services (114.3 CMR 50.00) at www.mass.gov/eohhs/gov/laws-regs/hhs/regs.html. Click on Regulations.

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

Providers are reminded that only emergency services that are necessary to treat an acute medical condition requiring immediate care are allowed for members who have MassHealth limited coverage as described in 130 CMR 450.105 (G)(1):

Covered Services. For MassHealth limited coverage members (please see 130 CMR 505.008 AND 519.009), MassHealth will only pay for the treatment of a medical condition (including labor and delivery) that manifests itself by acute symptoms of sufficient severity that the absence of immediate medical attention reasonably could be expected to result in:

(A) Placing the member’s health in serious jeopardy,

(B) Serious impairment to bodily functions, or

(C) Serious dysfunction of any bodily organ or part.

For questions, please contact MassHealth Customer Services at 1-800-841-2900 or email your inquiry to providersupport@mahealth.net.

MassHealth has posted the following publications on the MassHealth website:

Transmittal Letters from March 2013:

-ALL-199: Revised Regulations about Electronic 90-Day Waiver and Final Deadline Appeals file size 5MB

-ALL-198: Emergency Adoption of Mental Health Parity Regulations

-FAS-26: 2013 HCPCS

You can download a copy of a Bulletin or Transmittal Letter from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when Bulletins and Transmittal Letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

Providers are reminded that only emergency services that are necessary to treat an acute medical condition requiring immediate care are allowed for members who have MassHealth Limited Coverage as described in 130 CMR 450.105 (G)(1):

Covered Services. For MassHealth limited coverage members (please see 130 CMR 505.008 AND 519.009), MassHealth will only pay for the treatment of a medical condition (including labor and delivery) that manifests itself by acute symptoms of sufficient severity that the absence of immediate medical attention reasonably could be expected to result in:

(A) Placing the member’s health in serious jeopardy,

(B) Serious impairment to bodily functions, or

(C) Serious dysfunction of any bodily organ or part.

MassHealth will cover the following Dental Codes for members with limited coverage:

D0140, D0220, D0230, D0330, D7140, D7210 AND D9110

For questions, please contact MassHealth Dental Customer Services AT 1-800-325-5231 or email your inquiry to: INQUIRIES@MASSHEALTH-DENTAL.NET.

Therapy providers are reminded that they must follow the billing guidelines in Subchapter 6, Service Codes and Descriptions. Refer to Transmittal Letter THP-25, dated June 2011.  Modifier HA must be used when billing therapy evaluation service codes 97001, 97003 and 92506 for members aged 21 and under. Refer to Transmittal Letter THP-20, dated November 2003. To access these Transmittal Letters, go to www.mass.gov/masshealthpubs.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

MassHealth has identified underpayments of ACA section 1202 enhancement rates on certain claims submitted between January 01, 2013-March 01, 2013. The enclosed remittance advice may contain claims that were systematically adjusted to pay the enhanced fee. We apologize for the inconvenience.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

MassHealth understands that due to a unit-counting issue, MMIS inappropriately adjudicated a number of Early Intervention (EI) provider claims for service code T1024 (EI assessment) with edit 8155 (limit 40 units in 12 months), not allowing for the maximum of 40 units per 12- month period.

To appropriately allow the maximum of 40 units per 12-month period, units of T1024 for dates of service on or after July 01, 2011 are being counted based on a MOVING DATE OF SERVICE (DOS) anniversary date, with MassHealth beginning to count the 40 units based on the first DOS for which the claim for T1024 is filed. For example, if an EI provider submits an a claim for T1024 with the first DOS of March 06, 2013, the EI provider may then bill an accumulation of 40 units of T1024 during the 12-month period beginning on DOS March 06, 2013 and ending March 05, 2014. After March 05, 2014 and having reached the 12-month mark from the first DOS on the claim, MassHealth will begin counting another 40 units toward the next 12-month period, based on the DOS of the T1024 claim that is received after March 05, 2014. For example, if a claim is submitted with the first DOS of May 06, 2014, then MassHealth will again begin counting up to 40 units in the 12-month period beginning May 06, 2014 and ending May 05, 2015.

MassHealth will systematically reprocess previously adjudicated claims for T1024 due to edit 8155, for DOS July 01, 2011 and following, on future remittance advices. No action is required on the part of the provider.

We apologize for any inconvenience this may have caused. For questions, including information on the appeals process, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Please be advised that the Executive Office of Health and Human Services (EOHHS) has updated the Hospice Rates for MassHealth Hospice Providers, pursuant to regulation 101 CMR 343.00. The updated Hospice rates are effective for dates of service October 01, 2012 –September 30, 2013. MassHealth will process mass retro rate adjustments in April 2013. No further action is required by Hospice Providers.

If you have questions, contact MassHealth Customer Service at 1-800-841-2900. Updated Hospice Rates are available at EOHHS’s website at www.mass.gov/eohhs/gov/laws-regs/hhs/regs.html.

MassHealth has posted the following publications on the MassHealth website:

Provider Bulletins from February 2013:

-Acute Outpatient Hospital Bulletin 28: Drug Screen/Quantitative Drug Test Claim Edit; Drug Screens Performed For Residential Monitoring
-All Provider Bulletin 233: Revisions to the 90-Day Waiver Procedures
-All Provider Bulletin 232: Revisions to the Final Deadline Appeal Procedures
-All Provider Bulletin 231: Payment Error Rate Measurement (PERM) Project
-Community Health Center 74: Drug Screen/Quantitative Drug Test Claim Edit; Drug Screens Performed For Residential Monitoring
-Independent Clinical Laboratory Bulletin 9: Drug Screen/Quantitative Drug Test Claim Edit; Drug Screens Performed For Residential Monitoring
-Physician Bulletin 94: Drug Screen/Quantitative Drug Test Claim Edit; Drug Screens Performed For Residential Monitoring

Transmittal Letters from February 2013:

-ALL-197: Revised Appendix C

You can download a copy of a Bulletin or Transmittal Letter from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when Bulletins and Transmittal Letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

In response to the flu vaccine crisis, MassHealth wants to inform physicians, group practices and independent nurse practitioners that you will be reimbursed for privately-purchased flu vaccine if you exhaust your state-provided supply from local boards of health or the Massachusetts Department of Public Health (MDPH).

In accordance with 130 CMR 433.443 (c)(2)(a), reimbursement for privately-purchased vaccine can be obtained by using the following codes: 90655, 90656, 90657, 90658, 90660, 90661 and 90662.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

In response to the flu vaccine crisis, MassHealth wants to inform community health centers that they will be reimbursed for privately-purchased flu vaccine if they exhaust their state-provided supply from local boards of health or the Massachusetts Department of Public Health (MDPH).

Reimbursement for privately-purchased vaccine can be obtained by using the following codes: 90655, 90656, 90657, 90658, 90660, 90661 and 90662.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

In response to the flu vaccine crisis, MassHealth wants to inform limited services clinics that they will be reimbursed for privately-purchased flu vaccine if they exhaust their state-provided supply from local boards of health or the Massachusetts Department of Public Health (MDPH).

Reimbursement for privately-purchased vaccine can be obtained by using the following codes: 90655, 90656, 90657, and 90658.

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

All Provider Bulletin 225, dated April 2012, communicates the circumstances in which to use each Delay Reason Code when submitting Direct Data Entry (DDE) claims via the Provider Online Service Center (POSC). Delay Reason Code 11 – OTHER includes, but is not limited to, NCCI/MUE related reviews and special circumstances. DDE claims for submissions of Final Deadline Appeals (9) or 90-Day Waiver Requests (1, 4 or 8) should be submitted with the appropriate Delay Reason Code, as noted. Additionally, claims submitted with TPL attachments, Sterilization forms, Hysterectomy forms or Invoices are not required to submit with Delay Reason Code 11 unless the circumstance is specifically outlined in the bulletin referenced above.

Please remember to include a brief cover letter as to why special handling is needed and include the supporting documentation, as well as any applicable remittance advices, with your DDE claim submission. Erroneous selections of Delay Reason Codes may cause delays in claims processing or result in claims denials.

Go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/. Click on Provider Bulletins, then 2012 Bulletins, then April. For questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

The POSC was designed with security protocols that allow access to a provider’s information by only authorized individuals. This process is accomplished with the assignment of a primary user for each provider. The primary user then has the responsibility to grant subordinate permissions to provider staff for the functions they need. The primary user is also required to maintain user IDs by removing access for those who leave the provider or change job functions.

Maintaining subordinate access is a requirement that is mandated by regulation to notify MassHealth of any change in information. If a primary user no longer has that role, the provider must assign a new primary user and remove the previous user’s access as necessary. Providers are not permitted to continue to use the primary user ID of someone who is no longer employed. Providers should audit their primary user(s) and subordinate(s) to be certain that they are up-to-date.

MassHealth has posted the following publications on the MassHealth website:

Provider Bulletins from December 2012

• All Provider Bulletin 230: Section 1202 Rates for Physicians Who Provide Primary Care Service

You can download a copy of a bulletin or transmittal letter from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when bulletins and transmittal letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

The Massachusetts Health Quality Partners (MHQP) has released the 2012 Pediatric and Adult Preventive Care Guidelines and Immunization Schedules. They can be accessed via the MHQP web site.

For Pediatric Preventive Care Recommendations, go to: www.mhqp.org/guidelines/pedPreventive/pedPreventive.asp?nav=041100

For Adult Preventive Care Guidelines, go to:
www.mhqp.org/guidelines/adultPreventive/adultPreventive.asp?nav=040900

MassHealth has implemented a processing change for Part B crossover claims billed by group practice providers.

As of 12/16/12, all Part B crossover claims submitted by group practice providers will be priced based on the rendering provider ID submitted in the claim detail. Previously, MassHealth priced these claims based on the billing provider ID. The rendering provider ID must be on file with MassHealth and is required on the claim submission. The following informational edits will appear on your remittance advice if the rendering provider ID is not on file or is not eligible to bill the service: Edit 1007 -DETAIL RENDERING PROVIDER I.D. NOT ON FILE or Edit 1002 -DTL PERFORMING PROV NOT ELIG AT SERV LOC FOR PROG.
Group practice providers are responsible for ensuring that all individuals who practice as rendering providers in the group are enrolled and active providers with MassHealth before claims may be submitted for payment. Failure to do so may result in claims denials.

Effective January 01, 2013, four (4) modifiers have been added to the list of modifiers that providers can use, when medically appropriate and in accordance with CMS regulations, to bypass National Correct Coding Initiative (NCCI) procedure code to procedure code (PTP) edits.

The following two new HCPCS modifiers will be added to the list of allowable PTP associated modifiers for Medicaid fee-for-service claims subject to the Practitioner (PRA) NCCI edits and Outpatient Hospital (OPH) NCCI edits:

LM – LEFT MAIN CORONARY ARTERY
RI – RAMUS INTERMEDIUS CORONARY ARTERY

The following two existing CPT modifiers will be added to the list of designated PTP-associated modifiers for use for Medicaid fee-for-service claims subject to PRA NCCI edits, but not for claims subject to OPH NCCI edits:

24 – UNRELATED MANAGEMENT AND EVALUATION SERVICE BY THE SAME PHYSICIAN DURING POST-OPERATIVE PERIOD
57 – DECISION FOR SURGERY

Note that these two modifiers have previously been allowable by MassHealth for purposes of bypassing global surgery edits. For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900. For general information on modifier use, please see Provider Bulletin 227.

On 12/02/2012, MassHealth implemented a system change to allow third party liability claim payment for MassHealth non-covered services provided to MassHealth QMB members with Medicare Advantage Plan coverage. Claims processed on or after 12/02/2012 for MassHealth non-covered services provided to members with Medicare Advantage will be paid if there is a remaining MassHealth liability on the claim.

As a result of this change, providers may see the following new EOB codes on remittance advices:

1806 - PAID PATIENT RESPONSIBILITY AMOUNT (header)
1807 - PAID PATIENT RESPONSIBILITY AMOUNT (detail)

MassHealth plans to reprocess previously denied claims and will provide an update in a future message. For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Nursing Facility providers are reminded that they must follow the billing guidelines in Bulletin 133, dated May 2012, as well as the guidelines published in Transmittal Letter NF 58, dated December 2011, when billing claims for members with Medicare, Medicare Advantage and/or other insurance coverage.

Claims denying for Edit 2528 - POTENTIAL MEDICARE A IN FIRST 100 DAYS, Edit 2556 – POTENTIAL MEDICARE C IN FIRST 100 DAYS or Edit 2557 – POTENTIAL PRIVATE INSURANCE IN FIRST 100 DAYS can be resolved by following the instructions in the above-mentioned publications. Go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/ and click on the links for Bulletins and Transmittal Letters. For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Providers are advised that MassHealth has made enhancements on the POSC for all COB claim submissions.  Certain COB fields in the Coordination of Benefits and Procedure tabs will now auto-populate for you:

Coordination of Benefits Tab: In the “Coordination of Benefits (COB) Detail” panel, if the “Relationship to Subscriber,” is “18-Self”,  there is now an option to click “Populate Subscriber” which will auto-populate the following data fields that have already been entered on the “Billing and Service” tab:

-Subscriber Last Name

-Subscriber First Name

-Subscriber Address

-Subscriber City

-Subscriber State

-Subscriber Zip Code

Procedure tab: In the COB Line Details panel, the following data fields will auto-populate from the information that has been entered on the “Coordination of Benefits” tab and “Institutional/Professional Service Detail” panel:

-Carrier Code (if multiple carrier codes have been entered from the “Coordination of Benefits” tab, there will be a drop down to select the appropriate carrier code)

-Paid Units of Service

-Revenue Code (applies to Institutional claims)

-Procedure Code

For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

Effective 10/01/2012, service code 92340 (Fitting of spectacles, except for aphakia; monofocal) was included on the NCCI Medically Unlikely Edit list, limiting this service code to one unit per date of service. 

To receive payment for fitting two pairs of eyeglasses instead of bifocals for members, providers must now bill service code 92340 with a single unit on two claim lines.  The first claim line must be reported with no modifier and the second claim line with modifier 59 (Distinct procedural service).  For claims which have already denied under edit code 5930 (MUE Units Exceeded), please re-bill these claims as described above rather than submitting an appeal.

The 2013 Current Procedural Terminology (CPT) manual, published by the American Medical Association (AMA), has made some major changes to psychiatric procedure codes. 

The following codes, previously allowed for Mental Health Centers, will no longer be valid for dates of service after January 01, 2013: 90801, 90862, 90804, 90806, 90816 and 90818.  Medication Management services previously billed under 90862 should now be billed as an evaluation and management office visit (99213). 

New psychiatric codes covered for Mental Health Centers include:

90791 - Psychiatric Diagnostic Evaluation
90832 - Psychotherapy, 30 minutes with patient and/or family member
90833 - Psychotherapy, 30 minutes with patient and/or family member when performed with E&M service
90834 - Psychotherapy, 45 minutes with patient and/or family member
90836 – Psychotherapy, 45 minutes with patient and/or family member when performed with E&M service
99213 - Office or other outpatient visit for evaluation and management

Please refer to the 2013 CPT manual for details regarding these codes.

MassHealth understands that due to the recent CMS NCCI quarterly update, MMIS has been denying Early Intervention provider claims for service code T1015 –TL (clinic visit/encounter, all-inclusive) when more than one unit is billed, with denial edit 5930 (MUE units exceeded).

MassHealth has reviewed this matter and has implemented a change to address this issue to ensure that future Early Intervention claims for T1015 TL will process according to MassHealth regulations and as stated in subchapter 6 of the Early Intervention provider manual. We will systematically reprocess previously adjudicated claims for T1015 denied due to edit 5930 on future remittance advices. No action is required on the part of the provider.

We apologize for any inconvenience this may have caused. For questions, please contact MassHealth Customer Service at providersupport@mahealth.net or call 1-800-841-2900.

MassHealth has posted the following publications on the MassHealth website:

Provider Bulletins from November 2012

-All Provider Bulletin 229: Physician Designees and the Ambulance Medical Necessity Form   

-Nursing Facility Bulletin 134: Nursing Facility Pay for Performance (NF P4P) Program for 

 Fiscal Year (FY) 2013  

You can download a copy of a transmittal letter or bulletin from the online Provider Library (www.mass.gov/masshealthpubs).

To sign up for e-mail alerts when bulletins and transmittal letters have been posted on our website, go to www.mass.gov/masshealth/pcm or call MassHealth Customer Service at 1-800-841-2900.

Effective Monday, December 3, 2012, providers who submit Prior Authorization (PA) requests via the MMIS Provider Online Service Center (POSC) will no longer be able to add a line item to a previously adjudicated PA. 

To modify an existing PA on the POSC, providers must submit a NEW PA request for the procedure code and the number of units being requested for review.  When submitting a new PA request for an adjustment or modification, providers must enter ADJUSTMENT/MODIFICATION in the PROVIDER COMMENTS section and, if applicable, include the active PA number to be adjusted/modified along with units already used/billed. With the exception of adjustment requests to change the size of absorbent products, the provider must include all required documentation to justify the medical necessity of the request, including a letter signed by the member’s prescribing provider that states the reason for the adjustment/modification and prescription, if required.

Upon receipt of the adjustment/modification request, the Prior Authorization Unit (PAU) will review for medical necessity and adjudicate the request as appropriate.

If you have any questions regarding this information, please contact the PAU at 1-800-862-8341 or PriorAuthorization@umassmed.edu.

MassHealth is currently experiencing delays in processing suspended claims submitted via Direct Data Entry (DDE) with Delay Reason Code 11.  In order to maintain a 120-day suspension period for edit 829 - NCCI APPEAL/SPECIAL HANDLE UNDER REVIEW, MassHealth is working diligently to review claims requiring special handling.

Providers are advised to select the appropriate delay reason code for special handling claims, as outlined in All Provider Bulletin 225, April 2012, Special Circumstances for Electronic Claims. Erroneous selections may cause delays in review and claims processing or claims denials.  Go to www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/.  Click on Provider Bulletins, then 2012 Bulletins, then April.

We apologize for the delay and thank you for your patience.  If you have questions, contact MassHealth Customer Service at providersupport@mahealth.net or 1-800-841-2900.

Providers are reminded to verify member eligibility using the Provider Online Service Center (POSC) before rendering services.

In addition, before submitting claims, please be sure to check all tabs and view the member's eligibility details by clicking on the date range to verify whether the member has other health insurance, is assigned to a Primary Care Clinician (PCC) Provider for referrals or has any other eligibility restrictions.

The Verify Member Eligibility online job aid offers instructions for this function. Go to 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. Under Eligibility Verification, click Verify Member Eligibility.

Remember to check the global time frame attached to the service code being billed for a member in order to avoid the following edits:

8175 – SERVICE PROVIDED ON THE SAME DAY OF A GLOBAL SURGICAL PROCEDURE IS INCLUDED IN FEE AMOUNT

8176 – SERVICE PROVIDED ON THE DAY OF AND DURING 10-DAY GLOBAL SURGICAL PROCEDURE INCLUDED

8177 – SERVICE PROVIDED DAY BEFORE AND DURING 90-DAY GLOBAL SURGICAL PROCEDURE INCLUDED

8253 – VISIT AND SURGERY NOT ALLOWED SAME DAY/SAME POS

Please refer to Payment for Global Surgical Package regulations (130 CMR 433.452(B)) located in the MassHealth Physician Manual. For additional information about the National Correct Coding Initiative (NCCI) and associated modifiers, please refer to MassHealth All Provider Bulletin 209 (April 2011) and All Provider Bulletin 227 (June 2012).

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As a MassHealth provider, you are reminded that, in accordance with MassHealth regulation 130 CMR 450.223(B), you must notify MassHealth in writing within 14 days of any profile information that has changed since your initial enrollment. This includes, but is not limited to, changes in ownership or control, criminal convictions, address changes or license status. Failure to notify MassHealth constitutes a breach of the provider contract and may result in termination of the provider contract or other sanctions. The absence of notification constitutes confirmation of no changes.

To submit changes through the Provider Online Service Center (POSC), go to www.mass.gov/masshealth/providerservicecenter and click on the Manage Provider Information link, then on Maintain Profile and then on Update Your MassHealth Profile. Providers without Internet access may submit changes in writing to Provider Enrollment and Credentialing, PO Box 9118, Hingham, MA 02043.

The POSC was designed with security protocols that allow access to a provider’s information by only authorized individuals. This process is accomplished with the assignment of a primary user for each provider. The primary user then has the responsibility to grant subordinate permissions to provider staff for the functions they need. The primary user is also required to maintain user IDs by removing access for those who leave the provider or change job functions.

Maintaining subordinate access is a requirement that is mandated by regulation to notify MassHealth of any change in information. If a primary user no longer has that role, the provider must assign a new primary user and remove the previous user’s access as necessary. Providers are not permitted to continue to use the primary user ID of someone who is no longer employed. Providers should audit their primary user(s) and subordinate(s) to be certain that they are up-to-date.