Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth All Provider Bulletin 147 October 2005 TO: All Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Policy Regarding MCO Claims Submission Background This bulletin notifies providers of recent updates made to policies and procedures for MassHealth managed care organization (MCO) claims submissions. These updates were made due to the growing confusion among providers about the MassHealth MCO claims submission policy and a steady rise in providers and billing agencies submitting requests for claims assistance to the MassHealth MCO program. MCO Claim Submission Policy MassHealth MCOs are required to honor the enrollment information contained in the MassHealth Recipient Eligibility System (REVS). The REVS enrollment information takes precedence over any MassHealth MCO-specific enrollment system. Accordingly, MassHealth does not adjust the REVS enrollment information to correspond with information contained in an MassHealth MCO’s enrollment system. Please do not submit the following to the MassHealth MCO Enrollment Unit: ▪ a request that MassHealth REVS enrollment information be updated or adjusted; ▪ a notification that a member is not enrolled with an MCO; or ▪ a request that MassHealth remove an insurance restriction. If you receive an explanation of benefits from a MassHealth MCO stating that a member is not eligible on certain dates of service, please confirm the member’s enrollment via REVS. If REVS indicates that the member was in fact enrolled in the MCO on the dates of service, please contact the MCO directly and advise the MCO to: ▪ verify REVS enrollment information; ▪ update its enrollment information to reflect REVS, if applicable; and ▪ reprocess the claim, if applicable. If REVS confirms that the member was not enrolled in a MassHealth MCO on the dates of service and reports that the member was eligible for MassHealth on the date of service, please submit the claim directly to MassHealth following standard claim submission practice. (continued on back) MassHealth All Provider Bulletin 147 October 2005 Page 2 When to contact the MassHealth MCO Enrollment Unit Please submit requests for assistance to the MassHealth MCO Enrollment Unit only in the event that a claim was denied by both MassHealth and the MCO. In order to enable a complete review of claims meeting this criterion, please submit the following items to the MassHealth MCO Enrollment Unit via fax at 617-573-1843: ▪ a copy of the remittance advice detailing the denial reason from MassHealth; ▪ a copy of the remittance advice detailing the denial reason from the MCO; and ▪ a copy of the REVS printout verifying eligibility was checked on the date of service. In such cases, if MassHealth ultimately determines that the MassHealth MCO wrongfully denied the claim, MassHealth will forward the claimto the MCO for reprocessing, along with verification of the member’s enrollment dates. MassHealth does not call providers to verify that such claims have been received or processed. Please consult your related remittance advices for confirmation. Questions If you have any questions about the information in this bulletin 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.