Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth

MassHealth
All Provider Bulletin 216
September 2011

TO:	All Providers Participating in MassHealth

FROM:	Julian J. Harris, Medicaid Director

RE:	HIPAA 5010 Diagnosis Code Requirement


New Requirement
The Centers for Medicare & Medicaid Services (CMS) has mandated that, effective 
January 1, 2012, the standards for electronic health care transactions must change 
from version 4010/4010A1 to version 5010. MassHealth is actively working toward 
this implementation date (see All Provider Bulletin 210). 
Effective January 1, 2012, all MassHealth providers submitting claims via electronic, 
paper, or direct data entry (DDE) must include a valid diagnosis code on the claim.
Providers must use the ICD-9-CM diagnosis codes or, if applicable, use diagnosis 
codes from the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 
4th Edition Text Revision).
This change also impacts MassHealth providers who are not currently required to 
submit diagnosis codes with their claim submissions.
This new requirement does not apply to dental providers submitting claims on the 
ADA (American Dental Association) claim form.


Claims without Required Diagnosis Code 	
MassHealth will take the following actions on claims that do not contain the required  
diagnosis code on or after January 1, 2012. 

* Electronic transactions will be rejected. Providers will receive a 999R 
acknowledgement notice that confirms to the submitter that their transaction has 
been rejected and will not be processed.
* DDE transactions will receive an error message upon data entry indicating that a 
diagnosis code must be entered. If no diagnosis code is entered, the claim 
cannot be submitted.
* Paper claims will be denied. Providers will receive the details about the denial on 
the remittance advice.
 
Please Note: Effective January 1, 2012, MassHealth is moving toward an
all-electronic claims submission policy to achieve greater efficiency. MassHealth
intends to require electronic claim submission unless the provider has received an 
approved electronic claim submission waiver. Related changes to MassHealth 
regulations will be described in a future provider transmittal letter.
	
Please see All Provider Bulletin 212 for more information about MassHealth’s paper 
claims policy.
	

System Requirements
Providers should confirm that their systems have the ability to support this 5010 
change.
Providers using a software vendor or billing intermediary should confirm with their 
vendor that they have the ability to support this change.
	

Effective Date
This change is effective January 1, 2012.
	

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.