- Electronic Claims Submission
- Online Claims Status
- Member Eligibility Verification
- Electronic Authorization
Electronic Claims Submission
Please Note: Effective January 1, 2012, MassHealth is moving toward an all-electronic claims submission policy to achieve greater efficiency. All claims must be submitted electronically, unless the provider has received an approved electronic claim submission waiver. 90-day waiver requests and final deadline appeals may be submitted either electronically via the Provider Online Service Center or on paper.
Please see All Provider Bulletin 217, dated September 2011, for more information about MassHealth’s paper claims waiver policy. For information on how to submit 90-day waiver requests and final deadline appeals electronically, please also see All Provider Bulletin 220 and All Provider Bulletin 221, dated December 2011.
Currently, over 96% of all claims processed by MassHealth are submitted electronically. Electronic claims submission is the most efficient, accurate, and cost-effective method. If you are not submitting electronic claims and you currently have a software vendor or billing intermediary that supports your billing operation, contact them about getting set up to bill MassHealth electronically. Our staff will be happy to assist you and your vendor to transition to electronic billing easily and quickly. We encourage you to view the Approved HIPAA Vendor List to see if your vendor currently works with MassHealth.
If you do not have a vendor but would like to bill MassHealth electronically, consider submitting your batch claims directly to MassHealth or using direct data entry (DDE) functionality on the MassHealth Provider Online Service Center (POSC) to submit claims and attachments.
The POSC is a secure Web site that allows providers to submit and receive HIPAA-compliant transactions (i.e., ANSI 837) using the Internet. Providers may also submit coordination of benefits (COB) claims via 837P or 837I COB batch transactions or by using the DDE functionality on the POSC. DDE is available to all approved MassHealth providers.
For more information, please contact MassHealth Customer Services Center at 1-800-841-2900.
Web-Based MassHealth Transactions
MassHealth has launched a secure Web site for all providers, except retail pharmacies, for exchanging electronic transactions. This new Web application allows providers to submit and download HIPAA-complaint claims (ANSI 837) via the internet.
Online Claims Status
To ensure that providers are aware of the adjudication status of claims in at timely manner, MassHealth offers in addition to the MassHealth Remittance Advice, an online claims status system either by using vendor software or the Provider Online Service Center. For additional information, view All Provider Bulletin 117 .
835 Health Care Claim Payment/Advice
Providers who submit electronic claims may receive the 835 Health Care Claim Payment/Advice. The 835 provides adjudication and payment information, and a growing number of providers are working with their software vendors to integrate them into their payment systems to support automated posting of receivables. Providers are encouraged to receive and use this data to support business operations.
Member Eligibility Verification
Verifying member eligibility and coverage is a critical best business practice. There are several options available to support this task including a Web based option on the Provider Online Service Center or accessing via a data clearinghouse such as NEHEN or WebMD. MassHealth provides an Automated Voice Response (AVR) system that can be accessed by calling 1-800-554-0042. Providers must have a user ID and password to access AVR.
Verify member eligibility information from the eligibility verification system (EVS) on the Provider Online Service Center. From your Web browser, you will have access to all the information available from the other methods. Because there is no limit on the number of inquiries you may perform, you can access EVS via the Internet as often as necessary. You may check member eligibility by member identification number, social security number, or the member's last name, first name, and date of birth. For more information, call the MassHealth Customer Services Center at 1-800-841-2900.
In addition to the review of your online remittance advice and 835, there is another tool available to determine MassHealth payments.
Vendor Web: The office of the State Comptroller provides an online source for financial information. Using this Web site, providers can easily and quickly access their payment information, view scheduled payments, view payment history and request electronic funds transfer (EFT). Visit https://massfinance.state.ma.us/VendorWeb/vendor.asp for more information.
Electronic Funds Transfer
Providers are encouraged to take advantage of Electronic Funds Transfer (Direct Deposit) where your MassHealth payment will be transferred to a bank account of your choice via Electronic Funds Transfer (EFT). EFT/Direct Deposit offers the following advantages over traditional reimbursement via paper check:
- Timely access to funds
- Reduced administrative burden
- Elimination of lost, stolen, or misdirected checks
MassHealth Customer Services Center
P.O. Box 9162
Canton, MA 02021
Additional information on EFT/Direct Deposit.
The Provider Online Service Center (POSC) enables providers to both submit and receive via the Internet a response to a prior-authorization (PA) request for a medical service or product that requires PA. With this electronic option, providers can attach documentation to their request electronically. When the attachments needed to determine medical necessity (for example, photographs and X rays) must be mailed, providers will be instructed to identify the mailed attachments, and they will then be re-associated with the PA request that was submitted electronically.
This information is provided by MassHealth.