Billing MassHealth after a commercial insurance pays the claim
Electronic Billing: Billing MassHealth after a commercial insurance pays the claim is referred to as Coordination of Benefits (COB) billing. If you are currently billing HIPAA-compliant 837 claims, MassHealth recommends that you check with your software vendor to ensure that 837 COB claims are supported.
Once the primary insurance has made a payment, you may submit your claim to MassHealth for processing, indicating the primary insurance payment in the "other paid amount" field. The claim will process and the other paid amount will be deducted from the MassHealth allowed amount. The claim will be paid up to the MassHealth allowed amount.
Important Paper Claims Information: Effective January 1, 2012, MassHealth is moving toward an all-electronic claims submission policy to achieve greater efficiency. MassHealth intends to require electronic claims submission, unless the provider has received an approved electronic claim submission waiver. Please see All Provider Bulletin 217 for more information about MassHealth’s paper claims waiver policy.
MassHealth MCOs, Private HMOs, and Other Primary Insurers
Private insurance is the primary insurance for the member, which makes MassHealth the secondary payer. These claims cannot be billed directly to MassHealth. These services may be billed to MassHealth for secondary payment by indicating the amount paid by the primary insurance, along with the EOB from the primary insurance attached to the claim.
For members enrolled in a MassHealth MCO, the MassHealth MCO must be billed for the services covered by the MCO contract. Most services rendered to the member are covered by the MCO contract with very few exceptions. Some services not covered by the MCO contract are covered directly by MassHealth as long as the member is eligible for the benefit under the applicable coverage type. Some examples of services covered directly by MassHealth include non-emergent dental services, personal care attendant services, and non-medical vision care. Services covered directly by MassHealth should be billed directly to MassHealth. For a list of services covered directly by MassHealth please consult your billing regulations.
This information is provided by MassHealth.