Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth All Provider Bulletin 226 June 2012 TO: All Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Final Deadline Appeal Submissions – New Request for Claim Review Form Background MassHealth has worked with several statewide health plans to develop a common claim review form. The resulting Request for Claim Review Form was adopted in July 2011 by private health plans in Massachusetts. An accompanying Request for Claim Review Reference Guide is a provider resource for submission criteria and documentation requirements for each health plan. Final Deadline Appeal Submissions MassHealth is adopting the Request for Claim Review Form. Effective immediately, MassHealth providers can submit this form with each final deadline appeal (FDA) for claims with service dates that exceed one year and that comply with MassHealth regulations at 130 CMR 450.323. The form can be submitted electronically with your final deadline submission via the Provider Online Service Center (POSC). Please refer to All Provider Bulletin 221 (December 2011) for information about the electronic claim submission process for final deadline appeals. MassHealth providers must select only the MassHealth Final Deadline Appeal box on the Request for Claim Review Form when submitting final deadline appeals to MassHealth. Final Deadline Appeal Resources The Request for Claim Review Form and Reference Guide are available on the HealthCare Administrative Solutions Web site at www.hcasma.org by clicking a link in the left margin. Please refer to the MassHealth document that provides answers to frequently asked questions. It is accessible at www.mass.gov/eohhs/docs/masshealth/ provider-services/final-deadline-appeal-faqs.pdf 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.