Adjusting a paid claim with the correct internal control number (ICN)

To adjust a paid claim, enter the most recently paid ICN. Incorrectly paid claims can be adjusted when you are not changing the member ID, claim form type, or provider number. For more information, please read Corrective Action for Incorrectly Paid Claim (PDF) pdf format of    flyer_corrective-action-for-incorrectly-paid-claim  txt format of flyer_corrective-action-for-incorrectly-paid-claim .

Correcting data-entry errors

If your claim was denied as a result of a data-entry error, you do not need to rebill it if the image of the claim in the system is clear and correct. A MassHealth Customer Service representative will reprocess the claim. Please call 1-800-841-2900 to request that the claim be reprocessed. MassHealth will reprocess keying errors over the telephone, unless the image of the original claim is so poor that it cannot be reimaged/reprocessed. In that case, the provider will be asked to rebill the claim.

Suspended claims

A suspended claim is a claim that has been received, but that requires review before final adjudication. When a claim appears as suspended on your remittance advice (RA), the ICN assigned to the claim will remain the same throughout the processing cycle. You should post the claim as received by MassHealth; do not rebill the claim. The suspended claim will appear on a subsequent RA as paid or denied.

The Final Deadline Appeal Process

New Final Deadline Appeal Form

Effective June 1, 2012, MassHealth providers can now submit a final deadline appeal request to MassHealth using the Request for Claim Review form.

This form and its accompanying reference guide is the result of a collaborative effort between the Massachusetts Health Care Administrative Simplification Collaborative (HCAS), MassHealth, and several statewide health plans.  The form was adopted in July 2011 by private health plans in Massachusetts to ease administrative burdens for providers in managing different appeal forms with different payers.

The Request for Claim Review form and the Reference guide are available at the HCAS Web site www.hcasma.org. To facilitate the transition to the new form, please read MassHealth answers to frequently asked questions pdf format of    Final Deadline FAQs  txt format of Final Deadline FAQs .

MassHealth denies any claim received more than 12 months after the date of service (up to 18 months for those involving a third party insurer) for exceeding the final billing deadline. It may, however, be submitted for consideration as a final deadline appeal when the criteria below are met.

A claim submitted after 36 months from the oldest date of service cannot be appealed and will appear on the remittance advice as denied.

Criteria for Filing a Final Deadline Appeal

The provider must meet all of the following criteria.

  • The claim must have service dates over 12 months or 18 months when another insurer is involved.
  • The claim must have appeared as denied on a remittance advice for "Final Deadline Exceeded."
  • The appeal must be filed within 30 days of the date on the remittance advice that first denied the claim for this reason.
  • MassHealth must have denied or underpaid the claim as a result of a MassHealth error.
  • You must have exhausted all available correction procedures outlined in these administrative and billing instructions, before the final deadline.
  • You must have originally submitted the claim in a timely manner.

Accompanying Documentation

You must submit the following documentation with each claim for which you are requesting a final deadline appeal:

  • a cover letter with a statement that describes the MassHealth error that resulted in the denial or underpayment of the claim;
  • a copy of each remittance advice on which the claim has appeared, including the one on which the claim was denied for "Final Deadline Exceeded;"
  • any other documentation supporting your claim; and
  • a legible and accurately completed paper claim form.

Requests for final deadline appeals should be sent to the appropriate address listed in Appendix A pdf format of    appx-a-all.pdf  of your MassHealth provider manual.

After review, you will receive a letter either approving or denying the appeal request. Any further communication about that appeal should be addressed to the person who signed the letter. For more information, please read Billing Timelines & Appeal Procedures (PDF) pdf format of    flyer-billing-timelines-and-appeal-procedures.pdf  txt format of flyer-billing-timelines-and-appeal-procedures.txt .

Payment Amount Per Episode (PAPE)

Implementation Guides Frequently asked questions about PAPE (PDF) pdf format of    pape-qa.pdf  txt format of pape-qa.txt


This information is provided by MassHealth.