Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111	
	MassHealth
	Community Health Center Bulletin 53
	August 2003

	TO:	Community Health Centers Participating in MassHealth

	FROM:	Douglas S. Brown, Acting Commissioner

	RE:	Services Provided by a Medicare-Noncertified Clinician

Background	This bulletin outlines billing procedures for claims for dually entitled (Medicare/MassHealth) members receiving behavioral-health services performed by clinicians who are not Medicare-certified providers.  (Clinicians who do not meet Medicare’s clinical criteria are “noncertified,” and therefore cannot bill Medicare for their services.)  This bulletin supersedes the “Claims for Non-certified Clinicians” section of Community Health Center Bulletin 32, dated November 1996.  The information in this bulletin contains specific MassHealth electronic billing guidelines, which are not described in the HIPAA implementation guides for the 837 professional transaction, as well as instructions for paper submissions.
	
	Providers must continue to bill Medicare for all services provided by a certified Medicare provider before billing MassHealth.  The procedures in this bulletin should be used only when a service is not reimbursable by Medicare because a noncertified clinician provided the service.

837P Transaction	When submitting an 837 professional (837P) transaction for services provided by a noncertified clinician, providers must populate the other payer loops (2320 and 2330) in the transaction with Medicare’s information and the MassHealth-assigned carrier code of 085, even though the service has not been billed to Medicare.  Do not populate any Medicare payments, coinsurance, or deductibles in the other payer loops (2320 & 2330) in the transaction.  In addition, do not populate the service-line adjudication in the 2430 loop.  

	If the member also has commercial insurance, then providers must bill the insurance before billing MassHealth.  Providers must also populate the other payer loops (2320, 2330, and 2430) in the 837P transaction with all applicable third-party-insurance information.    

											

Paper and EMC	Providers no longer need to submit the explanation of noncovered 
Submissions	Medicare benefits (EONMB) when billing for services performed by a noncertified clinician.  Providers may submit the claim on the medical services claim form (no. 9) or in the current electronic claim (EMC) format, using the appropriate behavioral-health service code.  In lieu of attaching the EONMB, providers should enter a code of 01 in the patient status field (Item 19 on claim form no. 9) to indicate that a noncertified clinician performed the services.

Questions	If you have any questions about the information in this bulletin, please contact MassHealth Provider Services at 617-628‑4141 or 1‑800‑325‑5231.