Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth All Provider Bulletin 237 September 2013 TO: All Providers Participating in MassHealth FROM: Kristin Thorn, Acting Medicaid Director RE: Primary Care Clinician (PCC) Plan Referral Process and Requirements Background A PCC referral system that generates a unique referral number for each PCC Plan member for each specialty provider referral was released in 2009 with NewMMIS to improve the PCC’s ability to track and monitor PCC Plan member care. MassHealth has reviewed the list of services that do and do not require referral for a member enrolled in the PCC Plan and has updated the claims editing processes accordingly. Effective for dates of service beginning September 23, 2013, PCCs must use the MMIS PCC referral process for referrals to servicing/specialty care providers. Servicing/specialty care providers must include the PCC’s referral number on the claims in order to receive payment. Nine-Digits Requirement for Claims Processing PCCs must enter their referral information by direct data entry (DDE) through the Provider Online Service Center (POSC). Once the referral data are entered, MMIS generates a unique nine-digit referral number for the member. Claims for dates of service beginning Monday, September 23, 2013, must contain the unique nine-digit referral number. A provider number is not an appropriate referral number. For example, claims submitted with a legacy provider ID plus leading zeros will be denied with the error message 3121 (Invalid referral number.) When using the POSC, PCCs and servicing/specialty-care providers can obtain the unique referral numbers issued for members by selecting “Manage Service Authorizations,” then “Referrals,” and then “Inquire Referral.” This will display the Referral Search panel so the provider can locate the referral number. Continued on next page MassHealth All Provider Bulletin 237 September 2013 Page 2 For additional instructions about submitting, updating and reviewing referrals, please review the job aids found at www.mass.gov/masshealth/newmmis and select “Need Additional Information or Training,” and then select “Get Trained.” Payment for MassHealth Services Payment for services remains subject to all conditions and restrictions of MassHealth, including but not limited to, the scope of covered services for a member’s coverage type, service limitations, additional services that do not require a PCC referral, and prior-authorization (PA) requirements. Please refer to 130 CMR 450.105 for a list of the services covered for each MassHealth coverage type and applicable program regulations for descriptions of covered services and specific service limitations; 130 CMR 450.118(J)(5) for additional services that do not require a PCC referral; and 130 CMR 450.303, 450.144(A)(2), and applicable program regulations for PA requirements. 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.