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

                                                  MassHealth
                                                  Transmittal Letter MHC-44 
                                                  December 2011



	TO:	Mental Health Centers Participating in MassHealth

	FROM:	Julian J. Harris, M.D., Medicaid Director 

	RE:	Mental Health Center Manual (Revised Appendix D)

The Centers for Medicare & Medicaid Services (CMS) requires all trading partners who submit 
electronic transactions to convert from Health Insurance Portability and Accountability Act 
(HIPAA) Accredited Standards Committee (ASC) X12 Version 4010A1 to HIPAA ASC X12 
Version 5010. All covered entities (health care providers, health plans, and health care 
clearinghouses) must be HIPAA 5010 compliant by January 1, 2012. 

This letter transmits a revised Appendix D for the Mental Health Center Manual. Appendix D 
contains revised billing instructions required for HIPAA version 5010/5010A1 for submitting 
837P transactions, direct data entry (DDE), and paper claims for dually entitled 
(Medicare/MassHealth) members receiving behavioral-health services provided by clinicians 
who are not Medicare-certified providers. Only clinicians who do not meet Medicare’s clinical 
criteria are considered noncertified for purposes of these instructions. These instructions do not 
apply to providers who meet Medicare clinical criteria, but do not participate in Medicare.

Appendix D contains specific MassHealth billing instructions that supplement the instructions 
found in the HIPAA 837P Implementation Guide, in the MassHealth 837P Companion Guide, 
and in the MassHealth Billing Guide for the CMS-1500.  
Please Note: Effective January 1, 2012, MassHealth is moving toward an all-electronic claims 
submission policy to achieve greater efficiency. All claims must be submitted electronically, 
unless the provider has received an approved electronic claim submission waiver. 90-day 
waiver requests and final deadline appeals may be submitted either electronically via the POSC 
or on paper. Please see All Provider Bulletin 217, dated September 2011, for more information 
about MassHealth’s paper claims waiver policy. Please also refer to All Provider Bulletin 220 
and All Provider Bulletin 221, dated December 2011, for information on how to submit 90-day 
waiver requests and final deadline appeals electronically.

The TPL Exception Form for Medicare Noncertified Clinicians has been obsoleted. Effective 
January 1, 2012, providers who have received an approved electronic claim submission waiver 
must use the TPL Exception Form that has been revised to reflect the 5010 mandate. To 
download the new form, go to www.mass.gov/masshealth. Click on MassHealth Provider Forms 
in the lower right panel of the home page, then scroll down the list to the TPL Exception Form. 

Providers must submit the CMS-1500 claim form with the revised TPL Exception Form to report 
total noncovered charges when billing MassHealth for behavioral health services that have been 
furnished by a Medicare noncertified provider. 

The revised Appendix D is effective January 1, 2012.


MassHealth Web Site

This transmittal letter and attached pages are available on the MassHealth Web site at 
www.mass.gov/masshealth.

Questions

If you have any questions about the information in this transmittal letter, 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.  

NEW MATERIAL
(The pages listed here contain new or revised language.)

Mental Health Center Manual

Pages D-1 through D-4

OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)

Mental Health Center Manual

Pages D-1 through D-8 — transmitted by Transmittal Letter MHC-41
	MassHealth
	Transmittal Letter MHC-45
	December 2011
	Page 2


Supplemental Instructions for Services Provided by Medicare Noncertified 
Clinicians
This appendix contains supplemental billing instructions for claims submitted for dually eligible 
(Medicare/MassHealth) members receiving behavioral-health services provided by clinicians who are not 
Medicare-certified providers. Only clinicians who do not meet Medicare’s clinical criteria are considered 
noncertified for purposes of these instructions. These instructions do not apply to providers who meet 
Medicare clinical criteria, but do not participate in Medicare.
This appendix contains specific MassHealth billing instructions that supplement the instructions found in the 
HIPAA 837P Implementation Guide, the MassHealth 837P Companion Guide, and in the MassHealth Billing 
Guide for the CMS-1500.
The procedures in this appendix should be used only when a service is not reimbursable by Medicare, 
because behavioral health services were provided by a clinician who was not Medicare-certified. Providers 
must continue to bill Medicare for all services provided by a certified Medicare provider before billing 
MassHealth. Providers must retain the documentation that supports services performed by a Medicare 
noncertified clinician in their records for auditing purposes. If the member also has commercial insurance, 
providers must bill the commercial insurer before billing MassHealth.
MassHealth requires all claims to be submitted in an electronic format unless the provider has received an 
approved electronic claim submission waiver. Please refer to All Provider Bulletin 217.
TPL Requirements
To ensure that MassHealth is the payer of last resort, generally providers must make diligent efforts to get 
payment from other resources before billing MassHealth. See MassHealth regulations at 130 CMR 450.316. 
TPL Exceptions
There are instances where clinicians who do not meet Medicare’s clinical criteria are deemed Medicare 
noncertified, and therefore cannot bill Medicare for their services. If these exceptions exist, follow the 
instructions outlined in this appendix for claim submission. 
Billing Instructions for 837P Transactions
Providers must follow the HIPAA 837P Implementation Guide and the MassHealth 837P Companion Guide 
instructions. Complete the other payer loops in the 837P transactions as described in the following table 
when submitting claims to MassHealth for services that have been determined not covered by the other 
commercial insurance, if there is commercial insurance, and that meet the TPL exception criteria for 
Medicare noncertified clinicians. 
Loop
Segment
Value 
2320
SBR09 (Claim Filing Indicator)
MB
2320
AMT01 (Total Noncovered Amount Qualifier )
A8
2320
AMT02 (Total Noncovered Amount)
The total noncovered amount must = the 
total billed amount.
2330B
NM109 (Other Payer Name)
0085000


Billing Instructions for Direct Data Entry (DDE)
Providers must follow MassHealth billing guidelines. Complete the coordination of benefits (COB) fields in 
the provider portal direct data entry (DDE) claim panels, as described in the following table when submitting 
claims to MassHealth for services that have been determined to be not covered by the commercial insurer, if 
there is commercial insurance, and that meet the TPL exception criteria for Medicare noncertified clinicians. 
On the “Coordination of Benefits” tab, click “New Item” and complete the fields as described below.

COB Detail Panel
Field Name
Instructions
Carrier Code
Enter 0085000.
Carrier Name
Enter Medicare B.
Payer Claim Number
Enter 99.
Payer Responsibility
Select the appropriate code from the drop-down list.
Total Noncovered Amount
Enter the total billed amount. The total noncovered amount 
must = the total billed amount. 
Claim Filing Indicator
Enter MB.
Release of Information
Select the appropriate code from the drop-down list.
Assignment Benefit
Select the appropriate code from the drop-down list.
Subscriber Information Panel
Enter the appropriate required subscriber information: 
Subscriber last name 
First name
Subscriber ID
The relationship to the subscriber code (Select the 
appropriate code from drop-down list.) 
Please Note: Click “Add” to save the COB panel. 
Billing Instructions for Paper Claims
MassHealth requires all claims to be submitted in an electronic format unless the provider has received an 
approved electronic claim submission waiver. Please refer to All Provider Bulletin 217.
Providers must follow the instructions in the MassHealth Billing Guide for the CMS-1500. Providers must 
submit the CMS-1500 claim form with the TPL Exception Form to report total noncovered charges when 
behavioral health services are furnished by a Medicare noncertified provider. To download the new form, go 
to www.mass.gov/masshealth. Click on Masshealth Provider Forms in the lower right panel of the home 
page, then scroll down the list to the TPL Exception Form.


MassHealth’s Right to Appeal
MassHealth reserves the right to appeal any case that, in its determination, may meet the coverage criteria of 
an insurance carrier. Providers must, at MassHealth’s request, submit the claim and related clinical or service 
documentation to an insurance carrier if MassHealth determines that the provider’s submission is necessary 
in order for MassHealth to exercise its right to appeal.
Questions
If you have any questions about the information in this appendix, please refer to Appendix A of your 
MassHealth provider manual for the appropriate contact information.


























This page is reserved.
Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
Appendix D: Supplemental Instructions 
for TPL Exceptions
Page
D-1
Mental Health Center Manual
Transmittal Letter
MHC-44
Date
01/01/12