Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth All Provider Bulletin 225 April 2012 TO: All Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Special Circumstances for Electronic Claims Background The purpose of this bulletin is to instruct providers on certain special circumstances when submitting an electronic claim in accordance with the new MassHealth electronic claim policy. Effective January 1, 2012, all claims must be submitted electronically. Only providers with an approved electronic claim waiver may submit paper claims. Delay Reason Codes in Direct Data Entry (DDE) Providers submitting claims that require attachments and delay reason codes must submit them through direct data entry (DDE). Note that using the wrong delay reason code will delay claim processing. Claims requiring delay reason codes include the following. 90-Day Waivers can be submitted only with the following codes: 1 – Proof of eligibility unknown or unavailable; 4 – Delay in certifying provider; or 8 – Delay in eligibility determination. Final Deadline Appeals can be submitted using only Delay Reason Code 9 (Original claim rejected or denied due to a reason unrelated to the billing limitation rules). Please refer to All Provider Bulletin 220 (90-day waivers) and All Provider Bulletin 221 (final deadline appeals) for further information. Both bulletins were issued in December 2011. NCCI/MUE Appeal Requests and certain other claims that require special consideration can be submitted using only Delay Reason Code 11 (Other). Instructions for Submitting DDE Claims For instructions on submitting a DDE claim, see our POSC Job Aids. Go to the MassHealth Web site at www.mass.gov/masshealth and click on the Information for MassHealth Providers link, then on MassHealth Provider Trainings, and then NewMMIS Provider Training. Under the subheading Third Party Liability, click on either Professional Claim Submission to MassHealth with Coordination of Benefits or Institutional Claim Submission to MassHealth with Coordination of Benefits. (continued on next page) MassHealth All Provider Bulletin 225 April 2012 Page 2 Submitting Claims After Permedion HMS Review When submitting a claim reviewed by Permedion Health Management Systems (HMS), the claim must be submitted electronically via DDE using Delay Reason Code 11 (Other). These include: * a claim that was denied an inpatient admission by Permedion HMS but allowed to be billed as outpatient; * an outpatient claim where Permedion HMS has denied certain claim lines but can be resubmitted omitting the denied lines; * an inpatient claim that was billed incorrectly and Permedion HMS is instructing the provider to correct and resubmit the claim; and * an initial prepayment inpatient claim denied by Permedion HMS, but after a second review, the denial is overturned and the provider is instructed to submit a new claim. Scan and submit the Permedion HMS determination notice and other documentation in support of your request for review. If you are submitting multiple claims for the same member, submit each claim separately with a copy of the Permedion HMS notice. These must be scanned and included with a DDE claim submission. Use the Attachment tab in the POSC to upload the document. These claims will appear in a suspense status on your remittance advice with Edit 829 (NCCI Appeal/Special Handle under Review). A final decision will be reflected on a subsequent remittance advice when the claim is processed. Claims Denied for Edit 2614 A claim that was denied for Edit 2614 must be submitted electronically via DDE with Delay Reason Code 11 (Other). Providers must include a cover letter, medical records, and the remittance advice with the 2614 denial. The documents must be scanned and included with your DDE claim submission. Use the Attachment tab in the POSC to upload the documents. These claims will appear in a suspense status on your remittance advice with Edit 829 (NCCI Appeal/Special Handle under Review). A decision will be reflected when the claim appears processed on subsequent remittance advices. Other Circumstances Providers with any other special circumstance that requires review, including a diagnosis/procedure code conflict, should submit the claim via DDE using Delay Reason Code 11 and a brief letter explaining the situation. The letter, and any other accompanying documents, must be scanned and included with your DDE claim submission. Use the Attachment tab in the POSC to upload the documents. (continued on next page) MassHealth All Provider Bulletin 225 April 2012 Page 3 Personal Injury Protection (PIP) Claims MMIS has the ability to recognize a payor other than a health insurer, Protection (PIP) but in some cases when a provider has received partial payment from the casualty payor for Personal Injury Protection (PIP), the deduction may not be appropriately applied. This may result in a potential overpayment of a MassHealth claim. Until a system change is implemented to correct this issue, providers should submit all claims without the PIP payment and the PIP amount will be recovered via the recovery process. When third-party payments are received, providers should submit the following information along with a check, payable to the Commonwealth of Massachusetts, to the Casualty Recovery Unit: * member name and MassHealth ID number; * dates of service; * ICN; and * amount of overpayment. Providers should reimburse MassHealth within 45 days of receiving a MassHealth overpayment. The Casualty Recovery Unit will post the returned amount and issue a letter for future auditing purposes to reflect the return of funds. Please send the above information to the following address. Casualty Recovery Unit P.O. Box 15205 Worcester, MA 01615-0205 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.