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 201 

 February 2010 

 

 

 TO: All Providers Participating in MassHealth 

 

FROM: Terry Dougherty, Medicaid Director 

 

 RE: New Carrier Code Request Form 

 

 

 



Background A provider can now use the attached carrier code request form to 

report a commercial health insurance carrier that is not currently on the 
carrier code list in Appendix C of every MassHealth provider manual. The 
Third Party Carrier Code Request form is located on the MassHealth Web 
site at www.mass.gov/masshealth. Click on the link for MassHealth 
Provider Forms in the lower-right corner of the home page. 

 

The completed form should be faxed to 617-886-8134. You will receive a 
fax notification once your request has been processed. The new carrier 
code will be available for use in NewMMIS immediately, so MassHealth 
can update a member’s file with any update request that is received for 
the new carrier. The new carrier code will be seen on the carrier code list 
in Appendix C the next time Appendix C is updated. 

 

Please Note: This form should be used for its intended purpose only. It 
should not be used for any other MassHealth or Third Party Liability (TPL) 
Unit communications. 

 

Providers should continue to use the Third Party Liability Indicator form to 
report any changes to a MassHealth member’s third-party liability. You 
should continue to fax these forms to the TPL Unit using the fax number 
at the bottom of the form. 

 

 

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. 

. 

 



 

 




Third Party Carrier Code Request

Date: 

1. Commercial Carrier Information

 Insurance Company Name: 

 Insurance Company Phone No.: 

 Insurance Company Address: 

2. Policyholder and Family Information

 Policyholder’s Name: 

 SSN: Date of Birth: 

 Policy No.: Group No.: 

 Policy Start Date: Policy End Date: 

 Family Members Covered:

 Name: MassHealth ID No.: 

 Name: MassHealth ID No.: 

 Name: MassHealth ID No.: 

 Name: MassHealth ID No.: 

3. Provider Information

 Provider Name: 

 Contact Person: 

 Contact Phone No.: 

 Contact Fax No.: 

Please fax this form to: 
617-886-8134Assistant Manager
Revenue Operations Benefit Coordination

TPCCR (02/10)