Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter ALL-157 April 2008 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: All MassHealth Provider Manuals (Parts 3 and 5 of the Administrative and Billing Instructions) MassHealth is restructuring Subchapter 5, the Administrative and Billing Instructions, in all MassHealth provider manuals. Subchapter 5 contains information about eligibility verification, prior authorization, the paper remittance advice, claim form completion, correcting claims, error codes, and billing MassHealth for members who have other insurance. Except for Part 3 (Submitting Claims) and Part 5 (Remittance Advice), Subchapter 5 in every provider manual is generic and applies to all providers. MassHealth is now also converting Parts 3 and 5 of every provider manual into generic instructions that apply to all providers. This letter transmits revised Parts 3 and 5 of Subchapter 5 for all provider manuals. For most providers, this revision is very minor. Only the banner across the top of each page has changed. It now indicates that the page is the same for all providers. For two types of providers, the change is more obvious: Transportation providers: The revised Parts 3 and 5 replace provider-specific information about submitting paper transportation claims and reviewing the transportation remittance advice. This information has been updated and moved to a freestanding billing guide. To access the billing guide for claim form no. 7, go to www.mass.gov/masshealthpubs. Click on Provider Library, then on MassHealth Billing Guides for Paper Claim Submitters. Dental providers: The revised Parts 3 and 5 replace outdated provider-specific information about submitting dental claims. Dental providers should refer to the MassHealth Dental Program Office Reference Manual (ORM) for information about submitting claims and reviewing the remittance advice. A link to the ORM is on the Web page for MassHealth billing guides for paper claim submissions. Go to www.mass.gov/masshealthpubs. Click on Provider Library, then on MassHealth Billing Guides for Paper Claim Submitters. Claim-form-specific instructions for all providers, except pharmacies, are available on the MassHealth Web site at www.mass.gov/masshealthpubs. Click on Provider Library, then on MassHealth Billing Guides for Paper Claim Submitters. This Web page contains links to billing guides for each of the MassHealth paper claim forms. You can sign up to receive e-mail alerts when paper-claim-specific billing guides have been updated on the MassHealth Web site. Just go to the MassHealth Billing Guides for Paper Claim Submitters Web page and click on the link to sign up. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manuals Pages v, 5.3-1, 5.3-2, and 5.5-1 through 5.5-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Page v – transmitted by Transmittal Letter ALL-139 All pages in Parts 3 and 5 of Subchapter 5 of every provider manual printed before March 2008. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page v All Provider Manuals Transmittal Letter ALL-157 Date 04/01/08 5. Billing Instructions Part 1. Eligibility 5.1-1 Part 2. Prior Authorization 5.2-1 Part 3. Billing MassHealth 5.3-1 Part 4. Required Forms and Documentation 5.4-1 Part 5. Claim Status and Payment 5.5-1 Part 6. Error Codes and Explanations 5.6-1 Part 7. Claim Status and Claim Correction 5.7-1 Part 8. Other Insurance 5.8-1 Part 3. Billing MassHealth Electronic Claims Electronic submission is the most efficient, cost-effective, and accurate method of submitting claims for MassHealth payment. Electronic claims, on average, contain 25% fewer errors, and are processed faster than paper claims, due to reduced data-entry errors and the elimination of mailing and handling times. Pharmacy Claims All MassHealth retail and 340B pharmacy claims must be submitted electronically via the Pharmacy Online Processing System (POPS). ACS State Healthcare (ACS) operates POPS under the general framework of standards and protocols established by the National Council for Prescription Drug Programs (NCPDP). Pharmacy providers must work with their switch and software vendors to ensure compliance. Refer to the POPS Billing Guide for information about submitting claims via POPS. For information about pharmacy claim submission, visit www.mass.gov/masshealth/pharmacy, or contact the ACS Help Desk using the information found in Appendix A of your MassHealth provider manual. Dental Claims All claims for dental services are handled through the dental third-party administrator. For information about dental claim submission and the MassHealth dental program, contact the third-party administrator at the phone number listed in Appendix A of your MassHealth provider manual. All Other MassHealth Claims With the exception of pharmacy and dental providers (as directed above), all other MassHealth providers interested in submitting claims electronically should contact MassHealth Customer Service or the provider’s software vendor or billing intermediary. Dental providers should contact the MassHealth Dental Customer Service Center if they have any questions about MassHealth. There are several methods of electronic claim submission available, including direct billing, the use of a vendor (billing intermediary or clearinghouse) that submits claims on your behalf, and our free MassHealth Provider Claim Submission Software (PCSS). Direct Billing Electronic claims can be submitted directly to MassHealth using the secure Transactions Web site, accessible from www.mass.gov/masshealth. You must go through testing procedures before submitting claims electronically. If you are interested in submitting claims using this method, contact MassHealth Customer Service using the contact information listed in Appendix A of your MassHealth provider manual, to learn more about testing procedures. Dental providers should contact the MassHealth Dental Customer Service Center if they have any questions about MassHealth. Using a Vendor If you currently submit paper claims through a vendor, MassHealth Customer Service can assist you and your vendor in the transition to electronic billing. Dental providers should contact the MassHealth Dental Customer Service Center if they have any questions about MassHealth. If you do not currently have a vendor, but are interested in using one, we encourage you to view the MassHealth approved vendor list on the MassHealth Web site to find a vendor or to see if your vendor currently works with MassHealth. PCSS Along with facilitating MassHealth billing, the free MassHealth PCSS can capture and retain your provider and patient data and generate simple reports. To download the software and find additional product information, including the technical specifications needed to use PCSS, go to www.mass.gov/masshealth/pcss. If you have additional questions after reviewing these resources, contact MassHealth Customer Service using the information in Appendix A of your MassHealth provider manual. Dental providers should contact the MassHealth Dental Customer Service Center if they have any questions about MassHealth. Additional Resources More information about electronic billing is available in the MassHealth companion guides, found on the MassHealth Web site in the MassHealth Provider Library. Paper Claims Information about which claim forms you should use to bill MassHealth and instructions for completing and submitting paper claim forms to MassHealth are available online at www.mass.gov/masshealthpubs. Click on Provider Library, then on MassHealth Billing Guides for Paper Claim Submitters. Use these instructions along with the MassHealth regulations. The proper completion and submission of claim forms is essential for timely and accurate claims processing and payment. Part 5. Claim Status and Payment Claim Status After MassHealth processes a claim, the claim status is reported through the 276/277 transaction in the Recipient Eligibility Verification System (REVS) and on the MassHealth-issued remittance advice (RA). Pharmacy Claims For retail and 340B pharmacy claims, refer to the POPS Billing Guide for information about claim status (claim response formats). See page 5.5-2 for information about MassHealth payment to all providers, including pharmacy providers. Dental Claims All claims for dental services are handled through the dental third-party administrator. For information about dental claim submission and the MassHealth dental program, contact the third-party administrator at the phone number listed in Appendix A of your MassHealth provider manual. All Other Claims This section explains how to determine the status of a nonpharmacy claim. See page 5.5-2 for information about MassHealth payment to all other providers, including dental providers. MassHealth reports claim status and payment information through the 276/277 transaction and through its RAs. 276/277 Transaction The 276/277 HIPAA-compliant electronic transaction is the standard for claim-status inquiries to determine if a claim is paid, denied, or suspended. Claim status can be verified 24 hours a day, seven days a week through the 276/277 transaction using the claim status system in REVS. REVS can be accessed via the Web (WebREVS), or through REVS PC software. The 276/277 transaction provides fast and accurate information about the status of a claim. In order to use REVS for the 276/277 transaction, the submitter must be a MassHealth trading partner with a valid user ID and password. If you have questions about REVS or the claim status subsystem, contact the REVS Help Desk (see Appendix A of your MassHealth provider manual). If you do not have a user ID and password, contact HIPAA Support (see Appendix A). Remittance Advice The RA is a helpful tool when reconciling accounts, as it reports the status of a claim submitted to MassHealth. The RA is available in three forms: the 835 electronic RA, the supplemental electronic RA, and the paper RA. 835 Remittance Advice The 835 RA can be downloaded from the secure MassHealth Web site by a provider who has a signed trading partner agreement (TPA) on file with MassHealth. Testing for this transaction is not required. Format requirements and applicable standard codes are listed in the Implementation Guide, which can be accessed from the HIPAA section of the Washington Publishing Company (WPC) Web site. If you are not able to download this transaction from the MassHealth Web site, contact MassHealth Customer Service using the contact information listed in Appendix A of your MassHealth provider manual. Dental providers should contact the MassHealth Dental Customer Service Center. The MassHealth 835 Companion Guide provides MassHealth-specific information for the data content, codes, business rules, characteristics of the 835 transaction, technical requirements, and transmission options. The guide is available on the MassHealth Web site or by contacting MassHealth Customer Service using the contact information in Appendix A of your MassHealth provider manual. Dental providers should contact the MassHealth Dental Customer Service Center. Electronic Supplemental Remittance Advice The electronic supplemental RA file reports paid, denied, and suspended claims in the MassHealth RA format. Paper Remittance Advice The paper RA also displays information about claim status, although it appears in a format that is unique to MassHealth. The paper RA is sent to the “check mailing” address listed in your provider file. Generally, claims appear on an RA within 30 days of receipt by MassHealth (with the exception of Medicare crossover claims forwarded by the Medicare intermediary). For more information about account reconciliation using the paper RA, review the applicable MassHealth remittance advice and electronic equivalents guide for the claim type on which you bill. These documents are available in the Provider Library on www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library, then on MassHealth Billing Guides for Paper Claim Submitters. Both billing instructions and guides to remittance advices and electronic equivalents for each claim type are available from this page. Payment MassHealth offers two options for receiving payment for services provided to MassHealth members: electronic funds transfer (EFT) and paper checks. MassHealth strongly encourages providers to choose EFT for payment. Please note that all payments, whether electronic or by paper check, are issued by the Office of the Comptroller. Account reconciliation is the provider’s responsibility. Although MassHealth does not reconcile provider accounts, if you have a claim-related issue, contact MassHealth Customer Service using the information provided in Appendix A of your MassHealth provider manual. Dental providers should contact the MassHealth Dental Customer Service Center. Electronic Funds Transfer (EFT) EFT is a safe and secure payment method that allows MassHealth to directly deposit payment into a bank account designated by the provider. To receive payment through EFT, you must submit an application with an original signature to MassHealth. It will take approximately 14 business days to start receiving EFT payments after a completed application has been processed. Mail the EFT form to MassHealth Customer Service at the address listed in Appendix A of your MassHealth provider manual. More information is available on the MassHealth Web site at www.mass.gov/masshealth or the VendorWeb site, which can be accessed from https://massfinance.state.ma.us. Paper Check Providers who do not sign up for EFT receive payment through traditional paper checks. Paper checks are sent via U.S. mail and, therefore, may encounter time delays that the electronic methods of payment avoid. Reconciling the RA should be done with a corresponding check stub or transaction notification from the submitter’s financial institution. If you have additional questions about how to determine the status of a claim or which payment method is best for you, please contact MassHealth Customer Service using the contact information provided in Appendix A of your MassHealth provider manual. Dental providers should contact the MassHealth Dental Customer Service Center. VendorWeb VendorWeb is the Commonwealth’s online source for financial information. Once assigned a vendor code, providers can access information about payments issued to them by the Commonwealth through the VendorWeb site at https://massfinance.state.ma.us. For example, providers who receive payment via EFT can view their payment schedules online and download payment histories at their convenience. Providers receiving payment via paper checks can find their vendor code on their checks. Vendor codes are alpha-numeric, beginning with the letters “VC” followed by a 10-digit number. Vendor codes are not related to your federal tax identification number. If you receive EFT reimbursement, but are unsure of your vendor code, contact MassHealth Customer Service using the information provided in Appendix A of your MassHealth provider manual. Dental providers should contact the MassHealth Dental Customer Service Center. This page is reserved.