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-166 May 2009 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: All Provider Manuals (Revised Appendix A) This letter transmits a revised Appendix A for all provider manuals. Appendix A is a directory of MassHealth-related addresses, phone numbers, fax numbers, and e-mail addresses. Changes include: • updated MassHealth-related names, addresses, URL’s, and phone numbers; • the deletion of Legacy MMIS-related content; and • the addition of content reflecting the implementation of NewMMIS, and the systems that have been updated or will be in place with NewMMIS. Please Note: We will update Appendix A on our Web site as needed to keep it current. We do not send updates for Appendix A to providers unless requested. 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. You can also view, print, or download Appendix A from the MassHealth Web site at www.mass.gov/masshealthpubs. Click on Provider Library, then on MassHealth Provider Manual Appendices. The downloadable version of Appendix A is searchable, a significant advantage over the printed version. NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manuals Pages A-1 through A-20 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Pages A-1 through A-22 — transmitted by Transmittal Letter ALL-159 This appendix contains the names, addresses, and telephone numbers of units, agencies, and contractors that you may need to contact in the course of doing business with MassHealth. This appendix is also available on the MassHealth Web site at www.mass.gov/masshealthpubs. Click on Provider Library, then on MassHealth Provider Manual Appendices. This directory is organized alphabetically by function. Contents Claims Submission and Resolution: Dental Claims........................................................................................A-2 Claims Submission and Resolution.: Non-dental and Non-pharmacy Claims............................................... A-2 Claims Submission and Resolution: Pharmacy Claims................................................................................. ..A-4 Clinical Eligibility Assessment for Long-Term-Care Services...............................................……………… .A-4 Fraud Hotline................................................................................................................................................A-10 Hearings....................................................................................................................................................... A-10 Managed Care Information About MassHealth Members.…………………………….……………………A-10 Member Eligibility.......................................................................................................................................A-10 Payments.......................................................................................................................................................A-11 Prior Authorization: Dental Services ............................................................................................................A-12 Prior Authorization: Non-dental and Non-pharmacy Services......................................................................A-12 Prior Authorization: Pharmacy Services.......................................................................................................A-13 Provider Enrollment and Credentialing……………………………………………………………….……A-14 Provider Training..........................................................................................................................................A-15 Publications..................................................................................................................................................A-16 Third-Party Liability.....................................................................................................................................A-17 Utilization Management………………………………………………………………………… …………A-18 Vision Care Materials……………………………………………………………………………………….A-19 Claims Submission and Resolution: Dental Claims MassHealth has contracted with Dental Services of Massachusetts, Inc. (DSM) to serve as the dental third- party administrator. Doral Dental USA, LLC, is the subcontractor to DSM who will receive MassHealth dental claims and answer providers’ questions about the dental program. For information about dental prior authorization requests, see the section about Prior Authorization. Doral Customer Service: MassHealth Dental 12121 N. Corporate Parkway Mequon, WI 53092 www.masshealth-dental.net 1-800-207-5019 Verify member eligibility, provider customer service, questions about benefits, enrollment, credentialing, training, and complaints: 1-800-207-5019 1-800-466-7566 (TTY) Hours: Monday-Friday, excluding holidays, 8:00 A.M. – 6:00 P.M. Intervention Services: Member education, member appointment coordination, broken appointments assistance, and customer service for members: inquiries@mahealth-dental.net If you have questions about paper claims submission, claims inquiry, or claim status: 1-800-207-5019 Hours: Monday-Friday, excluding holidays, 8:00 A.M. – 6:00 P.M. claims@masshealth-dental.net Submit electronic claims (837 transactions) at www.masshealth- dental-net or through clearinghouse payer ID CKMA1 1-800-207-5019 Hours: Monday-Friday, excluding holidays, 8:00 A.M. – 6:00 P.M. eclaims@masshealth-dental.net Contact the Final Deadline Appeals Board If you have questions about final deadline appeals for dental claims. MassHealth Final Deadline Appeal Department 465 Medford Street P.O. Box 9708 Boston, MA 02144-9708 Claims Submission and Resolution: Non-dental and Non-pharmacy Claims MassHealth has contracted with MAXIMUS to receive MassHealth claims, except for pharmacy and dental claims, and to answer providers' questions about the payment of services covered by MassHealth. Providers are encouraged to submit claims electronically. MassHealth Customer Service: MassHealth ATTN: Customer Service P.O. Box 9118 Hingham, MA 02043 If you have questions about claims or MassHealth policy, or want to request a paper remittance advice: 1-800-841-2900 Hours: Monday-Friday, excluding holidays, 8:00 A.M. – 5:00 P.M. providersupport@mahealth.net If you have a question about the status of a claim: 1-800-841-2900 Hours: Monday-Friday, excluding holidays, 8:00 A.M. – 5:00 P.M. www.mass.gov/masshealthproviderservicecenter If you have questions about policies and procedures for submitting electronic claims, technical support, or testing for HIPAA claims transactions: 1-800-841-2900 Hours: Monday-Friday, excluding holidays, hiaasupport@mahealth.net After you are approved to submit claims electronically, upload your HIPAA-compliant electronic claims to the Web-Based Transactions page at: www.mass.gov/masshealthproviderservicecenter Send original paper claims to: MassHealth ATTN: Originals P.O. Box 9118 Hingham, MA 02043 Send paper adjustments of all paid claims to: MassHealth ATTN: Adjustments P.O. Box 9118 Hingham, MA 02043 Send paper resubmittals of all denied claims to: MassHealth ATTN: Resubmittals P.O. Box 9118 Hingham, MA 02043 Send voids of all claims paid in error to: MassHealth ATTN: Voids P.O. Box 9118 Hingham, MA 02043 If you have Medicare/MassHealth claims that do not cross over systematically, send paper crossover claims to: MassHealth ATTN: Crossover Claims P.O. Box 9118 Hingham, MA 02043 Send all 90-day waiver requests to: MassHealth ATTN: 90-Day Waivers P.O. Box 9118 Hingham, MA 02043 Contact the Final Deadline Appeals Board if you have questions about final deadline appeals for all claims, or if the service date on the claim exceeds 12 months (or 18 months, if another insurer is involved), and has received a final deadline-exceeded error code (0545 or 0853), submit your appeal to: MassHealth ATTN: Final Deadline Appeals 600 Washington Street Boston, MA 02111 617-210-5538 fdeappeals@state.ma.us Claims Submission and Resolution: Pharmacy Claims MassHealth has contracted with ACS State Healthcare (ACS) to receive MassHealth pharmacy claims and answer providers’ questions about the Pharmacy Online Processing System (POPS). For information about pharmacy prior authorization, see the section about Prior Authorization. If you have questions about billing and claims including questions about 90-day waiver requests ACS Technical Help Desk 1-866-246-8503 24 hours a day, seven days a week Fax the completed 90-day waiver form and any pertinent documentation to: 1-866-556-9315 (fax) If you need ID Card Request forms: 1-866-556-9313 (fax) For all other assistance with billing and claims: ACS Provider Relations MassHealth@Providerrelations@acs- inc.com If you have questions about member eligibility: MassHealth Customer Service 1-800-841-2900 Automated Voice Response (AVR): 1-800-554-0042 Send written questions related to claims or MassHealth policy to: ACS State Healthcare ATTN: MassHealth 260 Franklin Street, Suite 1020 Boston, MA 02110 masshealth.providerrelations@acs- inc.com If you have questions about registering for electronic remittance advice, or need a paper copy of your remittance advice: 1-800-841-2900 Hours: Monday-Friday, excluding holidays, 8:00 A.M. – 5:00 P.M. providersupport@mahealth.net Clinical Eligibility Assessment for Long-Term-Care Services The following Aging Service Access Points (ASAPs) are designated by MassHealth to perform clinical eligibility assessment activities for certain long-term-care services and programs (adult day health, nursing facility, and Program of All-inclusive Care for the Elderly (PACE)) for MassHealth members of all ages. Please send the necessary clinical documentation or PA request to the ASAP serving the town in which the member lives. Requests must be reviewed and approved by the ASAP before MassHealth will pay for a MassHealth member to receive the long-term-services and programs identified above. Clinical approval is a prerequisite for MassHealth payment. For assistance in locating the ASAP serving the member’s city or town, call 1-800-AGE-INFO. ASAP Service Area BayPath Elder Services, Inc. 354 Waverly Street Framingham, MA 01702 1-800-287-7284 or 508-872-1866 508-872-3325 (fax) 508-872-5012 (TTY) Ashland, Dover, Framingham, Holliston, Hopkinton, Hudson, Marlborough, Natick, Northborough, Sherborn, Southborough, Sudbury, Wayland, Westborough Boston Senior Home Care 110 Chauncy Street Boston, MA 02111 617-451-6400 617-451-6631 (fax) 617-695-0437 (TTY) Beacon Hill (West End), Charlestown, Chinatown, Columbia Point, Dorchester, East Boston, East Mattapan, North End, South Boston Bristol Elder Services, Inc. 182 North Main Street Fall River, MA 02720 1-800-427-2101 or 508-675-2101 508-679-0320 (fax) Attleboro, Berkley, Dighton, Fall River, Freetown, Mansfield, Norton, Raynham, Rehobeth, Seekonk, Somerset, Swansea, Taunton, Westport Central Boston Elder Services, Inc. 2315 Washington Street Boston, MA 02119 617-277-7416 or 617-277-7818 617-277-2005 (fax) 617-277-6691 (TTD) Allston, Back Bay, Brighton, Fenway, Jamaica Plain, North Dorchester, Parker Hill, Roxbury Chelsea/Revere/Winthrop Home Care Center, Inc. 100 Everett Ave, Unit 10 P.O. Box 6427 Chelsea, MA 02150-0008 617-884-2500 617-884-7988 (fax) 1-800-432-2370 (TTY) Chelsea, Revere, Winthrop Coastline Elderly Services, Inc. 1646 Purchase Street New Bedford, MA 02740 508-999-6400 508-993-6510 (fax) 508-994-4265 (TDD) Acushnet, Dartmouth, Fairhaven, Gosnold, Marion, Mattapoisett, New Bedford, North Dartmouth, Rochester Elder Services of Berkshire County, Inc. 66 Wendell Avenue Pittsfield, MA 01201 1-800-544-5242 or 413-499-0524 413-442-6443 (fax) 413-499-9764 (TTY) Adams, Alford, Becket, Cheshire, Clarksburg, Dalton, Egremont, Florida, Great Barrington, Hancock, Hinsdale, Lanesborough, Lee, Lenox, Monterey, Mount Washington, New Ashford, New Marlborough, North Adams, Otis, Peru, Pittsfield, Richmond, Sandisfield, Savoy, Sheffield, Stockbridge, Tyringham, Washington, West Stockbridge Elder Services of Cape Cod & the Islands, Inc. 68 Route 134 South Dennis, MA 02660-3774 1-800-244-4630 (on Cape Cod) 1-800-442-4492 (off Cape Cod) 508-394-4630 508-394-3712 (fax) 508-394-8691 (TDD/TTY) Barnstable, Bourne, Brewster, Buzzards Bay, Centerville, Chatham, Chilmark, Dennis, Eastham, Edgartown, Falmouth, Gay Head, Harwich, Hyannis, Mashpee, Nantucket, Oak Bluffs, Orleans, Provincetown, Sandwich, Tisbury, Truro, Vineyard Haven, Wellfleet, West Tisbury, Yarmouth Elder Services of Merrimack Valley, Inc. 360 Merrimack Street Riverwalk, Building 5 Lawrence, MA 01843-1740 1-800-892-0890 or 978-683-7747 978-687-1067 (fax) 1-800-924-4222 (TTY) Amesbury, Andover, Billerica, Boxford, Chelmsford, Dracut, Dunstable, Georgetown, Groveland, Haverhill, Lawrence, Lowell, Merrimack, Methuen, Newbury, Rowley, Salisbury, Tewksbury, Tyngsborough, Westford, West Newbury Elder Services of Worcester Area, Inc. 411 Chandler Street Worcester, MA 01602 1-800-243-5111 or 508-756-1545 508-754-7771 (fax) 508-792-4541 (TDD) Auburn, Barre, Boylston, Grafton, Hardwick, Holden, Leicester, New Braintree, Oakham, Paxton, Rutland Shrewsbury, West Boylston, Worcester ETHOS 555 Amory Street Jamaica Plain, MA 02130-2672 617-522-6700 617-524-2899 (fax) 617-524-2687 (TDD) Hyde Park, Roslindale, South Jamaica Plain, West Mattapan, West Roxbury Franklin Country Home Care Corporation 330 Montague City Road, Suite 1 Turners Falls, MA 01376-2530 1-800-732-4636 or 413-773-5555 413-772-1084 (fax) 413-772-6566 (TDD) Ashfield, Athol, Benardston, Buckland, Charlemont, Colrain, Conway, Deerfield, Erving, Gill, Greenfield, Hawley, Heath, Leverett, Leyden, Monroe, Montague, New Salem, Northfield, Orange, Petersham, Phillipston, Rowe, Royalston, Shelburne, Warwick, Wendell, Whately Greater Lynn Senior Services 8 Silbee Street Lynn, MA 01901 1-800-594-5164 or 781-599-0110 781-592-7540 (fax) 781-477-9632 (TDD) Lynn, Lynnfield, Nahant, Saugus, Swampscott Greater Springfield Senior Services, Inc. 66 Industry Avenue Springfield, MA 01104-4243 1-800-649-3641 or 413-781-8800 413-781-0632 (fax) 413-272-0399 (TTY) Agawam, Brimfield, East Longmeadow, Hampden, Holland, Longmeadow, Monson, Palmer, Springfield, Wales, West Springfield, Wilbraham HESSCO Elder Services One Merchant Street Sharon, MA 02067-1662 1-800-462-5221 or 781-784-4944 781-784-4922 (fax) Canton, Dedham, Foxborough, Medfield, Millis, Norfolk, Norwood, Plainville, Sharon, Walpole, Westwood, Wrentham Highland Valley Elder Services, Inc. 320 Riverside Drive, Suite B Florence, MA 01062-2700 1-800-322-0551 or 413-586-2000 413-584-7076 (fax) 413-585-8160 (TDD) Amherst, Blandford, Chesterfield, Chester, Cummington, Easthampton, Goshen, Granville, Hadley, Hatfield, Huntington, Middlefield, Montgomery, Northampton, Pelham, Plainfield, Russell, Southampton, Southwick, Tolland, Westfield, Westhampton, Williamsburg, Worthington Minuteman Senior Services 24 Third Avenue Burlington, MA 01803 1-888-222-6171 or 781-272-7177 781-229-6190 (fax) 781-273-3114 (TDD) Acton, Arlington, Bedford, Boxborough, Burlington, Carlisle, Concord, Harvard, Lexington, Lincoln, Littleton, Maynard, Stow, Wilmington, Winchester, Woburn Montachusett Home Care Corporation Crossroads Office Park 680 Mechanic Street Leominster, MA 01453-4402 1-800-734-7312 or 978-537-7411 978-537-9843 (fax) 978-534-6273 (TDD) Ashburnham, Ashby, Ayer, Berlin, Bolton, Clinton, Fitchburg, Gardner, Groton, Hubbardston, Lancaster, Leominster, Lunenberg, Pepperell, Princeton, Shirley, Sterling, Templeton, Townsend, Westminster, Winchendon Mystic Valley Elder Services 19 Riverview Business Park 300 Commercial Street Malden, MA 02148-7312 781-324-7705 781-324-1369 (fax) 781-321-8880 (TDD) Everett, Malden, Medford, Melrose, North Reading, Reading, Stoneham North Shore Elder Services 152 Sylvan Street Danvers, MA 01923 978-750-4540 978-750-8053 (fax) 978-624-2244 (TDD) Danvers, Marblehead, Middleton, Peabody, Salem Old Colony Elderly Services, Inc. 144 Main Street Brockton, MA 02301-4099 1-800-242-0246 or 508-584-1561 508-897-0031 (fax) 508-587-0280 (TDD) Abington, Avon, Bridgewater, Brockton, Carver, Duxbury, East Bridgewater, Easton, Halifax, Kingston, Pembroke, Hanover, Hanson, Lakeville, Marshfield, Middleborough, North Easton, Plymouth, Plympton, Rockland, Stoughton, Wareham, West Bridgewater, Whitman Senior Care, Inc. 5 Blackburn Center Gloucester, MA 01930-2259 1-866-927-1050 or 978-281-1750 978-281-1753 (fax) 978-282-1836 (TTY) Beverly, Essex, Gloucester, Hamilton, Ipswich, Manchester, Rockport, Topsfield, Wenham Somerville-Cambridge Elder Services 61 Medford Street Somerville, MA 02143-3429 617-628-2601 or 617-628-2602 617-628-1085 (fax) 617-628-1705 (TDD) Cambridge, Somerville South Shore Elder Services, Inc. 159 Bay State Drive Braintree, MA 02184 781-848-3910 or 718-749-6832 617-843-8279 (fax) 781-356-1992 (TDD) Braintree, Cohasset, Hingham, Holbrook, Hull, Milton, Norwell, Quincy, Randolph, Scituate, Weymouth Springwell 125 Walnut Street Watertown, MA 02472 617-926-4100 617-926-9897 (fax) 617-923-1562 (TTY) Belmont, Brookline, Needham, Newton, Waltham, Watertown, Wellesley, Weston Tri-Valley Elder Services, Inc. 10 Mill Street Dudley, MA 01571 1-800-286-6640 or 508-949-6640 508-949-6651 (fax) 508-949-6654 (TDD) Bellingham, Blackstone, Brookfield, Charlton, Douglas, Dudley, East Brookfield, East Douglas, Franklin, Hopedale, Medway, Mendon, Milford, Millville, Northbridge, North Brookfield, Oxford, Southbridge, Spencer, Sturbridge, Sutton, Upton, Uxbridge, Warren, Webster, West Brookfield, Whitinsville WestMass Elder Care, Inc. 4 Valley Mill Road Holyoke, MA 01040 1-800-462-2301 or 413-538-9020 413-538-6258 (fax) 1-800-462-2301 (TDD) Belchertown, Chicopee, Granby, Holyoke, Ludlow, South Hadley, Ware Adult Foster Care and Group Adult Foster Care Services The following ASAP performs clinical eligibility assessment activities for the adult foster care (AFC) and group adult foster care (GAFC) programs. Please send the applicable clinical documentation for all members seeking these services to: Coastline Elderly Services 1646 Purchase Street New Bedford, MA 02740 508-999-6400 508-993-6510 (fax) Clinical eligibility assessment requests must be reviewed by Coastline Elderly Services before a MassHealth member can be served by an AFC or GAFC program. Clinical approval is a prerequisite for MassHealth payment. Nursing Facility Services For all individuals seeking admission to a nursing facility, regardless of payer, who have a diagnosis of, or are suspected of having, mental illness, mental retardation, and/or development disability, a Level II Preadmission Screening Annual Resident Review (PASARR) is required before admission to a nursing facility. For MassHealth members or applicants who have a mental illness and are seeking admission to a nursing facility, call the Department of Mental Health’s designee, Health and Education Services (HES) at: HES 978-745-2440, Ext. 126 For MassHealth members or applicants who have mental retardation and/or developmental disabilities, and who are seeking admission to a nursing facility, contact the Department of Mental Retardation for the Level II PASARR: Referrals: 1-800-649-9378 To report admission: 617-624-7796 (Must be done on day of admission.) Fax page 1 of Level II PASARR to: 617-624-7557 (Must be done within 48 hours of admission.) Fraud Hotline Call the MassHealth Fraud Hotline to report all types of suspected MassHealth fraud. Leave a message on the voicemail box on weekends, holidays, and evenings. 1-800-437-2830 Hours: Monday-Friday, excluding holidays, 8:00 A.M. – 5:00 P.M. Hearings Applicants, members, and appeal representatives with questions about a fair hearing, and providers with questions about an adjudicatory hearing, should contact: Office of Medicaid Board of Hearings 2 Boylston Street Boston, MA 02116 617-210-5800 1-800-655-0338 617-210-5820 (fax) Managed Care Information About MassHealth Members MassHealth has entered into agreements with various entities to manage and review the quality and appropriateness of care. If you have questions about the PCC Plan, PCC Plan Network Management Services, or referral requirements: PCC Plan Hotline 1-800-495-0086 (TTY: 617-790-4130 for people with partial or total hearing loss) 617-790-4138 (fax) If you have questions about PCC Plan claims, PIP payments, provider enrollment and credentialing, or any new and existing referrals from PCCs: MassHealth Customer Service 1-800-841-2900 Hours: Monday-Friday, excluding holidays, 8:00 A.M. – 5:00 P.M. providersupport@mahealth.net If you have questions about service authorization or claims for members aged 65 or older enrolled in MassHealth Senior Care Options (SCO), contact the SCO Hotline at: 1-888-885-0484 Hours: Monday-Friday, excluding holidays, 9:00 A.M. – 5:00 P.M Member Eligibility The Eligibility Verification System (EVS) provides 24-hour access to member eligibility information for the previous four years, from current date of service. Be sure to have the member’s MassHealth identification number, social security number, or name, gender, and date of birth when making eligibility inquiries. EVS access methods require a user ID and password. If you have not submitted a Trading Partner Agreement, you cannot access EVS through the Online Service Center (POSC). The pharmacy claim-adjudication process at ACS includes the same eligibility verification that is available through EVS. Therefore, it is not necessary for retail pharmacists to separately validate member eligibility for pharmacy claims through EVS, through the Provider Online Service Center (POSC). Dental providers should validate member eligibility through the Doral system. Automated Voice Response (AVR): 1-800-554-0042 MassHealth Customer Service answers questions about: • EVS access methods (EVS and use of EVS PC software) • MassHealth cards • availability of EVS • how to verify eligibility 1-800-841-2900 Hours: Mon. – Fri., excluding holidays 8:00 A.M. – 5:00 P.M. NewMMIS Help Desk www.mass.gov/masshealthproviderservicecenter • Answers questions about installation of EVSpc software. • If members have questions about MassHealth, they should call MassHealth Customer Service at: 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss) Payments Providers are encouraged to receive MassHealth payments by electronic funds transfer (EFT). To receive payments by EFT, you must complete the Authorization for Electronic Funds Transfer (EFT) of MassHealth Payments form. The authorization form is available for download from our Web site at www.mass.gov/masshealth. Click on MassHealth Provider Forms in the lower-right panel on our home page. Your EFT request will not be approved unless you have a W-9 form on file. The W-9 form can also be downloaded from the Web according to the above instructions. Send the completed EFT form (and W-9 form, if applicable) to: MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 If you have questions about W-9 or EFT form completion: 1-800-841-2900 617-988-8974 (fax) providersupport@mahealth.net For replacement of a lost or damaged check: 617-210-5072 MassHealth payment information is available online. You may access the amount of your check or EFT by going to the Office of the State Comptroller’s Web site at www.mass.gov/massfinance. Go to VendorWeb and follow the instructions. Prior Authorization: Dental Services Some services need prior authorization (PA). These items are identified in Subchapters 4 and 6 of your MassHealth provider manual. If you have questions about prior authorizations: 1-800-207-5019 For non-dental PA see the section on Prior Authorization. Hours: Monday-Friday, excluding holidays pa@masshealth-dental.net Submit electronic PA requests at: www.masshealth-dental.net Mail all paper PA requests to: MassHealth Dental – PA 12121 N. Corporate Parkway Mequon, WI 53092 Prior Authorization: Non-dental and Non-pharmacy Services Some services require prior authorization (PA). These items are identified in Subchapters 4 and 6 of your MassHealth provider manual. Providers are encouraged to submit requests for prior authorization electronically. Submit electronic PA requests using the Provider Online Service Center at: www.mass.gov/masshealthproviderservicecenter Prior-authorization requests for non-pharmacy services including nutritional, enteral, diapers, med/hospital equipment, private duty nursing, PCA, vision care, speech therapy, occupational therapy, and physical therapy, should be sent to: MassHealth Customer Service P.O. Box 9154 Hingham, MA 02043 1-800-841-2900 PA Unit: 1-800-862-8341 PA Unit: 1-617-451-7000 Use the Provider Online Service Center or mail paper PA requests except those for Community Case Management (CCM) members to: MassHealth Customer Service Include name of program area: For Boston region use: P.O. Box 9154 Hingham, MA 02043 For Western region use: P.O. Box 9153 Hingham, MA 02043 Use the Provider Online Service Center or mail paper PA requests. www.mass.gov/masshealthproviderservicecenter Use the Provider Online Service Center, fax, telephone, or mail paper PA requests for CCM members for nursing, home health aide, physical therapy, occupational therapy, speech therapy, personal care attendant, durable medical equipment, and oxygen and respiratory therapy equipment: 508-421-5905 (fax) www.mass.gov/masshealthproviderservicecenter To inquire about the status of any PA request, call MassHealth Customer Service at: 1-800-841-2900 To inquire about PA for home health skilled nursing visits for MassHealth Basic members: 617-451-7132 Efax Customer Support If you have any questions or need technical assistance with your eFax account, contact eFax Customer Support by e-mail at: corporatesupport@mail.efax.com 1-800-810-2641 If you have questions about your password other than changing your password, or questions about a change in your enrollment status or questions about submitting prior authorizations to MassHealth, call MassHealth Customer Service at: 1-800-841-2900 Prior Authorization: Pharmacy Services Claims for certain drugs submitted through the Pharmacy Online Processing System (POPS) require prior authorization (PA). Please see Subchapter 4 of your provider manual and the MassHealth Drug List on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Drug List. Other claims will be denied because of certain drug utilization review (DUR) edits. When appropriate, the pharmacist should discuss the medical necessity of prescribing such drugs with the prescriber before calling for DUR certification. Use the following telephone and fax numbers to request DUR certification or to check on the status of your pharmacy PA request if you have not received a response within 24 hours. If you have not received a response within 24 hours, the pharmacist may provide a 72-hour supply of a requested covered drug. If you have questions about prior authorization: University of Massachusetts Medical School Drug Utilization Review Program Commonwealth Medicine 100 Century Drive Worcester, MA 01606 1-800-745-7318 1-877-208-7428 (fax) Send requests for all drugs that require PA to: Note: Telephone requests for PA will be accepted only in the case of a medical emergency. MassHealth Drug Utilization Review Program P.O. Box 2586 Worcester, MA 01613-2586 1-800-745-7318 1-877-208-7428 (fax) Provider Enrollment and Credentialing For All Providers Except Dental MassHealth has contracted with MAXIMUS to manage provider enrollment and credentialing activities, except for dental providers. Provider Enrollment and Credentialing establishes and maintains a file on every MassHealth provider. You must contact Provider Enrollment and Credentialing to report any changes in • your licensure and certification; • Medicare provider status; • ownership information; or • any other information submitted in your application. You may contact Provider Enrollment and Credentialing by telephone to • request a provider application; • ask about the status of your provider application; • verify your participation status; or • verify the information in your provider file. You must write to Provider Enrollment and Credentialing on your letterhead stationery and include your MassHealth provider ID/service location, NPI, and tax identification number to • report changes in information, such as your provider name and address; • change or add your Medicare provider number/service location to your MassHealth provider file; or • report a change in ownership. When you notify Provider Enrollment and Credentialing of a change in your Medicare provider ID/service location, you must include a copy of your Medicare Welcome Letter. When you notify Provider Enrollment and Credentialing of a change in your legal name, legal address and/or check mailing/remit address, you must include a signed Massachusetts Substitute W-9 Form, located at www.mass.gov/osc. To notify Provider Enrollment and Credentialing of any change in licensure, certifications, and qualifications or data that may affect participation in MassHealth, or to participate in the Primary Care Clinician Plan (PCCP), you must request a PCC Plan enrollment and credentialing application from MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 617-988-8974 (fax) Hours: Monday-Friday, excluding holidays 8:00 A.M. – 5:00 P.M. providersupport@mahealth.net For Dental Providers MassHealth has contracted with DSM/Doral to manage provider enrollment and credentialing activities for dental providers. Provider Enrollment and Credentialing establishes and maintains a file on every MassHealth dental provider. To inquire about enrollment and credentialing for dental providers: MassHealth Dental 12121 N. Corporate Parkway Mequon, WI 53092 1-800-207-5019 1-800-466-7566 (TTY) Hours: Monday-Friday, excluding holidays, 8:00 A.M. – 6:00 P.M. Provider Training For all providers, except pharmacy and dental providers, MassHealth has contracted with MAXIMUS to perform provider services, including training. To schedule a training or an individual consultation about billing for MassHealth services (except pharmacy and dental): MassHealth Provider Training P.O. Box 9118 Hingham, MA 02043 617-988-8974 (fax) providersupport@mahealth.net For pharmacy providers, MassHealth has contracted with ACS to perform provider services, including training. To schedule a training or individual consultation about billing for MassHealth pharmacy services: ACS State Healthcare ATTN: MassHealth 131 Tremont Street, 4th Floor Boston, MA 02111 617-423-1237 617-423-9846 (fax) masshealth.providerrelations@acs- inc.com To schedule a training or individual consultation about billing for MassHealth dental services: MassHealth Dental 12121 N. Corporate Parkway Mequon, WI. 53092 1-800-207-5019 1-800-466-7566 TTY Hours: Monday-Friday, excluding holidays 8:00 A.M. – 6:00 P.M. inquiries@masshealth-dental.net Publications The following is a list of sources where requests can be directed for various MassHealth publications. Written requests must be on your company letterhead and must include your provider ID/service location, tax identification number, and street address. Please note that the first replacement copy of a provider manual is provided free of charge. There will be a charge for additional copies. Most forms, all current MassHealth regulations, and all recent bulletins are available on the MassHealth Web site at www.mass.gov/masshealthpubs. Click on Provider Library. Provider manuals www.mass.gov/masshealthpubs MassHealth Provider Enrollment and Credentialing P.O. Box 9118 Hingham, MA 02043 1-800-841-2900 617-988-8973 (fax) Hours: Monday-Friday, excluding holidays 8:00 A.M. - 5:00 P.M. providersupport@mahealth.net EVS user guides www.mass.gov/masshealthpubs EVS Helpdesk 1-800-462-7738 Hours: Monday-Friday, excluding holidays 8:00 A.M. - 5:00 P.M. EVSHelpdesk@eds.com Transmittal letters and provider bulletins Requests must be made in writing. Include your provider ID/service location, address, telephone number, the exact title of the publication, and the date of the issuance. www.mass.gov/masshealthpubs MassHealth ATTN: Publications P.O. Box 9118 Hingham, MA 02043 617-988-8973 (fax) providersupport@mahealth.net Prior authorization forms (excluding dental), and other forms and publications Requests must be made in writing. Include your provider number, address, telephone number, and the exact title of the form. MassHealth ATTN: Forms Distribution P.O. Box 9118 Hingham, MA 02043 617-988-8973 (fax) Fee schedules It is helpful if you know the Code of Massachusetts Regulations (CMR) citation that applies to your provider type. Fee schedules are available free of charge online. There is a charge for paper copies. DHCFP also has the regulations available on disk. Division of Health Care Finance and Policy (DHCFP) 2 Boylston Street Boston, MA 02116 617-988-3100 www.mass.gov/dhcfp Please contact the State Bookstore if you cannot access the Internet. State Bookstore State House, Room 116 Boston, MA 02133 617-727-2834 ICD-9-CM, CPT, and HCPCS Code Books are available from the following sources: (Have your credit card ready. In addition, ICD-9-CM Code Books are available from some bookstores.) Ingenix 13931 Willard Road Chantilly, VA 20151 1-800-765-6588 801-536-1009 (fax) American Medical Association Order Department P.O. Box 930876 Atlanta, GA 31193-0876 1-800-771-7199 863-582-6845 (fax) Third-Party Liability Other Health Insurance MassHealth’s TPL Unit maintains the file that identifies other health insurance that a member may have. Other insurance information comes from various sources. If you receive written evidence (such as an explanation of benefits or a letter from an employer) that a member has other health insurance, different insurance than what is listed on the file, or no longer has health insurance coverage, please send the information to the TPL Unit. Mail or fax the insurance information to: (Please enclose copies of written evidence, if possible.) MassHealth TPL Unit P.O. Box 9212 Chelsea, MA 02150 617-357-7604 (fax) Medicare/Senior Plan Updates MassHealth’s Medicare Unit maintains the file that identifies Medicare or a third-party liability (TPL) senior plan that a member may have. If you receive written evidence (such as a health insurance card) that a member has Medicare or a senior plan/Medicare replacement policy, has a different insurance than what is listed on the file, or no longer has insurance coverage, please send the information to the Medicare Unit. This does not apply to a member whose benefits have been exhausted. It applies only to members who have terminated their enrollment, or transferred to another senior plan. Mail or fax the insurance information to: (Please enclose copies of written evidence, if possible.) MassHealth Medicare Unit The Schraffts Center 529 Main Street, 3rd Floor Charlestown, MA 02129 617-886-8133 (fax) Home Health Services Home health agency providers must submit a coverage determination from the primary insurer any time the member’s medical condition results in a change of skilled services in the plan of care, or when health insurance- coverage status, changes. Providers must submit the insurer’s EOB to MassHealth within 10 days of receiving notification of denial from the insurer. The EOB must include the member’s MassHealth identification number and accompany the Home Health Coverage Determination form. Mail or fax a copy of the EOB to: MassHealth Home Health Claims The Schraffts Center 529 Main Street, 3rd Floor Charlestown, MA 02129 617-886-8133 (fax) Utilization Management If you have questions about the Acute Hospital Utilization Management Program: Masspro 245 Winter Street Waltham, MA 02451-1231 781-890-0011 781-890-485 (fax) For Acute Preadmission Clinical Eligibility Assessment only: -800-732-7337 1-800-752-6334 For Acute Prepayment and Postpayment reviews: 781-290-5784 (fax) If you have questions about the Chronic Disease and Rehabilitation Hospital Utilization Management Program: Masspro 245 Winter Street Waltham, MA 02451-1231 781-890-0011 781-890-5485 (fax) For Chronic/Rehabilitation Preadmission, Clinical Eligibility Assessment Conversion Eligibility Assessment, and Concurrent Review: 1-800-554-5127 1-800-752-6334 (fax) For Chronic/Rehabilitation Postpayment Reviews: 781-290-5784 (fax) Vision-Care Materials All completed order forms for vision care materials must be either mailed or faxed to: MassCor Optical Laboratories P.O. Box 466 Gardner, MA 01440 1-888-482-7331 1-888-698-2020 (fax) 1-888-420-2047 (fax) To check the status of an order for vision care materials: MassCor Optical Laboratories 1-888-482-7331 1-888-420-2047 (fax) Monday-Friday: 9:00 A.M. – 4:00 P.M. This page is reserved.